Thumbnailjpg

Bioethics

BLACKWELL PHILOSOPHY ANTHOLOGIES

Each volume in this outstanding series provides an authoritative and comprehensive collection of the essential primary readings from philosophyrsquos main fields of study Designed to complement the Blackwell Companions to Philosophy series each volume represents an unparalleled resource in its own right and will provide the ideal platform for course use

1 Cottingham Western Philosophy An Anthology (second edition)2 Cahoone From Modernism to Postmodernism An Anthology (expanded second edition)3 LaFollette Ethics in Practice An Anthology (third edition)4 Goodin and Pettit Contemporary Political Philosophy An Anthology (second edition)5 Eze African Philosophy An Anthology6 McNeill and Feldman Continental Philosophy An Anthology7 Kim and Sosa Metaphysics An Anthology8 Lycan and Prinz Mind and Cognition An Anthology (third edition)9 Kuhse and Singer Bioethics An Anthology (second edition)

10 Cummins and Cummins Minds Brains and Computers ndash The Foundations of Cognitive Science An Anthology11 Sosa Kim Fantl and McGrath Epistemology An Anthology (second edition)12 Kearney and Rasmussen Continental Aesthetics ndash Romanticism to Postmodernism An Anthology13 Martinich and Sosa Analytic Philosophy An Anthology14 Jacquette Philosophy of Logic An Anthology15 Jacquette Philosophy of Mathematics An Anthology16 Harris Pratt and Waters American Philosophies An Anthology17 Emmanuel and Goold Modern Philosophy ndash From Descartes to Nietzsche An Anthology18 Scharff and Dusek Philosophy of Technology ndash The Technological Condition An Anthology19 Light and Rolston Environmental Ethics An Anthology20 Taliaferro and Griffiths Philosophy of Religion An Anthology21 Lamarque and Olsen Aesthetics and the Philosophy of Art ndash The Analytic Tradition An Anthology22 John and Lopes Philosophy of Literature ndash Contemporary and Classic Readings An Anthology23 Cudd and Andreasen Feminist Theory A Philosophical Anthology24 Carroll and Choi Philosophy of Film and Motion Pictures An Anthology25 Lange Philosophy of Science An Anthology26 Shafer‐Landau and Cuneo Foundations of Ethics An Anthology27 Curren Philosophy of Education An Anthology28 Shafer‐Landau Ethical Theory An Anthology29 Cahn and Meskin Aesthetics A Comprehensive Anthology30 McGrew Alspector‐Kelly and Allhoff The Philosophy of Science An Historical Anthology31 May Philosophy of Law Classic and Contemporary Readings32 Rosenberg and Arp Philosophy of Biology An Anthology33 Kim Korman and Sosa Metaphysics An Anthology (second edition)34 Martinich and Sosa Analytic Philosophy An Anthology (second edition)35 Shafer‐Landau Ethical Theory An Anthology (second edition)36 Hetherington Metaphysics and Epistemology A Guided Anthology37 Scharff and Dusek Philosophy of Technology ndash The Technological Condition An Anthology (second edition)38 LaFollette Ethics in Practice An Anthology (fourth edition)39 Davis Contemporary Moral and Social Issues An Introduction through Original Fiction Discussion and Readings40 Kuhse Schuumlklenk and Singer Bioethics An Anthology (third edition)

Bioethics

An Anthology

THiRD EDiTiON

Edited by

Helga Kuhse Udo Schuumlklenk and Peter Singer

This third edition first published 2016Editorial material and organization copy 2016 John Wiley amp Sons inc

Edition history Blackwell Publishing Ltd (1e 1999 and 2e 2006)

Registered OfficeJohn Wiley amp Sons Ltd The Atrium Southern Gate Chichester West Sussex PO19 8SQ UK

Editorial Offices350 Main Street Malden MA 02148‐5020 USA9600 Garsington Road Oxford OX4 2DQ UKThe Atrium Southern Gate Chichester West Sussex PO19 8SQ UK

For details of our global editorial offices for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at wwwwileycomwiley‐blackwell

The right of Helga Kuhse Udo Schuumlklenk and Peter Singer to be identified as the authors of the editorial material in this work has been asserted in accordance with the UK Copyright Designs and Patents Act 1988

All rights reserved No part of this publication may be reproduced stored in a retrieval system or transmitted in any form or by any means electronic mechanical photocopying recording or otherwise except as permitted by the UK Copyright Designs and Patents Act 1988 without the prior permission of the publisher

Wiley also publishes its books in a variety of electronic formats Some content that appears in print may not be available in electronic books

Designations used by companies to distinguish their products are often claimed as trademarks All brand names and product names used in this book are trade names service marks trademarks or registered trademarks of their respective owners The publisher is not associated with any product or vendor mentioned in this book

Limit of LiabilityDisclaimer of Warranty While the publisher and authors have used their best efforts in preparing this book they make no representations or warranties with respect to the accuracy or completeness of the contents of this book and specifically disclaim any implied warranties of merchantability or fitness for a particular purpose it is sold on the understanding that the publisher is not engaged in rendering professional services and neither the publisher nor the author shall be liable for damages arising herefrom if professional advice or other expert assistance is required the services of a competent professional should be sought

Library of Congress Cataloging‐in‐Publication data is available for this title

9781118941508 [paperback]

A catalogue record for this book is available from the British Library

Cover image Gustav Klimt designs for The Stoclet Frieze 1905ndash1909 Austrian Museum for Applied Art Vienna Photo by Fine Art imagesHeritage imagesGetty images

Set in 1012pt Bembo by SPi Global Pondicherry india

1 2016

Bioethics

BLACKWELL PHILOSOPHY ANTHOLOGIES

Each volume in this outstanding series provides an authoritative and comprehensive collection of the essential primary readings from philosophyrsquos main fields of study Designed to complement the Blackwell Companions to Philosophy series each volume represents an unparalleled resource in its own right and will provide the ideal platform for course use

1 Cottingham Western Philosophy An Anthology (second edition)2 Cahoone From Modernism to Postmodernism An Anthology (expanded second edition)3 LaFollette Ethics in Practice An Anthology (third edition)4 Goodin and Pettit Contemporary Political Philosophy An Anthology (second edition)5 Eze African Philosophy An Anthology6 McNeill and Feldman Continental Philosophy An Anthology7 Kim and Sosa Metaphysics An Anthology8 Lycan and Prinz Mind and Cognition An Anthology (third edition)9 Kuhse and Singer Bioethics An Anthology (second edition)

10 Cummins and Cummins Minds Brains and Computers ndash The Foundations of Cognitive Science An Anthology11 Sosa Kim Fantl and McGrath Epistemology An Anthology (second edition)12 Kearney and Rasmussen Continental Aesthetics ndash Romanticism to Postmodernism An Anthology13 Martinich and Sosa Analytic Philosophy An Anthology14 Jacquette Philosophy of Logic An Anthology15 Jacquette Philosophy of Mathematics An Anthology16 Harris Pratt and Waters American Philosophies An Anthology17 Emmanuel and Goold Modern Philosophy ndash From Descartes to Nietzsche An Anthology18 Scharff and Dusek Philosophy of Technology ndash The Technological Condition An Anthology19 Light and Rolston Environmental Ethics An Anthology20 Taliaferro and Griffiths Philosophy of Religion An Anthology21 Lamarque and Olsen Aesthetics and the Philosophy of Art ndash The Analytic Tradition An Anthology22 John and Lopes Philosophy of Literature ndash Contemporary and Classic Readings An Anthology23 Cudd and Andreasen Feminist Theory A Philosophical Anthology24 Carroll and Choi Philosophy of Film and Motion Pictures An Anthology25 Lange Philosophy of Science An Anthology26 Shafer‐Landau and Cuneo Foundations of Ethics An Anthology27 Curren Philosophy of Education An Anthology28 Shafer‐Landau Ethical Theory An Anthology29 Cahn and Meskin Aesthetics A Comprehensive Anthology30 McGrew Alspector‐Kelly and Allhoff The Philosophy of Science An Historical Anthology31 May Philosophy of Law Classic and Contemporary Readings32 Rosenberg and Arp Philosophy of Biology An Anthology33 Kim Korman and Sosa Metaphysics An Anthology (second edition)34 Martinich and Sosa Analytic Philosophy An Anthology (second edition)35 Shafer‐Landau Ethical Theory An Anthology (second edition)36 Hetherington Metaphysics and Epistemology A Guided Anthology37 Scharff and Dusek Philosophy of Technology ndash The Technological Condition An Anthology (second edition)38 LaFollette Ethics in Practice An Anthology (fourth edition)39 Davis Contemporary Moral and Social Issues An Introduction through Original Fiction Discussion and Readings40 Kuhse Schuumlklenk and Singer Bioethics An Anthology (third edition)

Bioethics

An Anthology

THiRD EDiTiON

Edited by

Helga Kuhse Udo Schuumlklenk and Peter Singer

This third edition first published 2016Editorial material and organization copy 2016 John Wiley amp Sons inc

Edition history Blackwell Publishing Ltd (1e 1999 and 2e 2006)

Registered OfficeJohn Wiley amp Sons Ltd The Atrium Southern Gate Chichester West Sussex PO19 8SQ UK

Editorial Offices350 Main Street Malden MA 02148‐5020 USA9600 Garsington Road Oxford OX4 2DQ UKThe Atrium Southern Gate Chichester West Sussex PO19 8SQ UK

For details of our global editorial offices for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at wwwwileycomwiley‐blackwell

The right of Helga Kuhse Udo Schuumlklenk and Peter Singer to be identified as the authors of the editorial material in this work has been asserted in accordance with the UK Copyright Designs and Patents Act 1988

All rights reserved No part of this publication may be reproduced stored in a retrieval system or transmitted in any form or by any means electronic mechanical photocopying recording or otherwise except as permitted by the UK Copyright Designs and Patents Act 1988 without the prior permission of the publisher

Wiley also publishes its books in a variety of electronic formats Some content that appears in print may not be available in electronic books

Designations used by companies to distinguish their products are often claimed as trademarks All brand names and product names used in this book are trade names service marks trademarks or registered trademarks of their respective owners The publisher is not associated with any product or vendor mentioned in this book

Limit of LiabilityDisclaimer of Warranty While the publisher and authors have used their best efforts in preparing this book they make no representations or warranties with respect to the accuracy or completeness of the contents of this book and specifically disclaim any implied warranties of merchantability or fitness for a particular purpose it is sold on the understanding that the publisher is not engaged in rendering professional services and neither the publisher nor the author shall be liable for damages arising herefrom if professional advice or other expert assistance is required the services of a competent professional should be sought

Library of Congress Cataloging‐in‐Publication data is available for this title

9781118941508 [paperback]

A catalogue record for this book is available from the British Library

Cover image Gustav Klimt designs for The Stoclet Frieze 1905ndash1909 Austrian Museum for Applied Art Vienna Photo by Fine Art imagesHeritage imagesGetty images

Set in 1012pt Bembo by SPi Global Pondicherry india

1 2016

BLACKWELL PHILOSOPHY ANTHOLOGIES

Each volume in this outstanding series provides an authoritative and comprehensive collection of the essential primary readings from philosophyrsquos main fields of study Designed to complement the Blackwell Companions to Philosophy series each volume represents an unparalleled resource in its own right and will provide the ideal platform for course use

1 Cottingham Western Philosophy An Anthology (second edition)2 Cahoone From Modernism to Postmodernism An Anthology (expanded second edition)3 LaFollette Ethics in Practice An Anthology (third edition)4 Goodin and Pettit Contemporary Political Philosophy An Anthology (second edition)5 Eze African Philosophy An Anthology6 McNeill and Feldman Continental Philosophy An Anthology7 Kim and Sosa Metaphysics An Anthology8 Lycan and Prinz Mind and Cognition An Anthology (third edition)9 Kuhse and Singer Bioethics An Anthology (second edition)

10 Cummins and Cummins Minds Brains and Computers ndash The Foundations of Cognitive Science An Anthology11 Sosa Kim Fantl and McGrath Epistemology An Anthology (second edition)12 Kearney and Rasmussen Continental Aesthetics ndash Romanticism to Postmodernism An Anthology13 Martinich and Sosa Analytic Philosophy An Anthology14 Jacquette Philosophy of Logic An Anthology15 Jacquette Philosophy of Mathematics An Anthology16 Harris Pratt and Waters American Philosophies An Anthology17 Emmanuel and Goold Modern Philosophy ndash From Descartes to Nietzsche An Anthology18 Scharff and Dusek Philosophy of Technology ndash The Technological Condition An Anthology19 Light and Rolston Environmental Ethics An Anthology20 Taliaferro and Griffiths Philosophy of Religion An Anthology21 Lamarque and Olsen Aesthetics and the Philosophy of Art ndash The Analytic Tradition An Anthology22 John and Lopes Philosophy of Literature ndash Contemporary and Classic Readings An Anthology23 Cudd and Andreasen Feminist Theory A Philosophical Anthology24 Carroll and Choi Philosophy of Film and Motion Pictures An Anthology25 Lange Philosophy of Science An Anthology26 Shafer‐Landau and Cuneo Foundations of Ethics An Anthology27 Curren Philosophy of Education An Anthology28 Shafer‐Landau Ethical Theory An Anthology29 Cahn and Meskin Aesthetics A Comprehensive Anthology30 McGrew Alspector‐Kelly and Allhoff The Philosophy of Science An Historical Anthology31 May Philosophy of Law Classic and Contemporary Readings32 Rosenberg and Arp Philosophy of Biology An Anthology33 Kim Korman and Sosa Metaphysics An Anthology (second edition)34 Martinich and Sosa Analytic Philosophy An Anthology (second edition)35 Shafer‐Landau Ethical Theory An Anthology (second edition)36 Hetherington Metaphysics and Epistemology A Guided Anthology37 Scharff and Dusek Philosophy of Technology ndash The Technological Condition An Anthology (second edition)38 LaFollette Ethics in Practice An Anthology (fourth edition)39 Davis Contemporary Moral and Social Issues An Introduction through Original Fiction Discussion and Readings40 Kuhse Schuumlklenk and Singer Bioethics An Anthology (third edition)

Bioethics

An Anthology

THiRD EDiTiON

Edited by

Helga Kuhse Udo Schuumlklenk and Peter Singer

This third edition first published 2016Editorial material and organization copy 2016 John Wiley amp Sons inc

Edition history Blackwell Publishing Ltd (1e 1999 and 2e 2006)

Registered OfficeJohn Wiley amp Sons Ltd The Atrium Southern Gate Chichester West Sussex PO19 8SQ UK

Editorial Offices350 Main Street Malden MA 02148‐5020 USA9600 Garsington Road Oxford OX4 2DQ UKThe Atrium Southern Gate Chichester West Sussex PO19 8SQ UK

For details of our global editorial offices for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at wwwwileycomwiley‐blackwell

The right of Helga Kuhse Udo Schuumlklenk and Peter Singer to be identified as the authors of the editorial material in this work has been asserted in accordance with the UK Copyright Designs and Patents Act 1988

All rights reserved No part of this publication may be reproduced stored in a retrieval system or transmitted in any form or by any means electronic mechanical photocopying recording or otherwise except as permitted by the UK Copyright Designs and Patents Act 1988 without the prior permission of the publisher

Wiley also publishes its books in a variety of electronic formats Some content that appears in print may not be available in electronic books

Designations used by companies to distinguish their products are often claimed as trademarks All brand names and product names used in this book are trade names service marks trademarks or registered trademarks of their respective owners The publisher is not associated with any product or vendor mentioned in this book

Limit of LiabilityDisclaimer of Warranty While the publisher and authors have used their best efforts in preparing this book they make no representations or warranties with respect to the accuracy or completeness of the contents of this book and specifically disclaim any implied warranties of merchantability or fitness for a particular purpose it is sold on the understanding that the publisher is not engaged in rendering professional services and neither the publisher nor the author shall be liable for damages arising herefrom if professional advice or other expert assistance is required the services of a competent professional should be sought

Library of Congress Cataloging‐in‐Publication data is available for this title

9781118941508 [paperback]

A catalogue record for this book is available from the British Library

Cover image Gustav Klimt designs for The Stoclet Frieze 1905ndash1909 Austrian Museum for Applied Art Vienna Photo by Fine Art imagesHeritage imagesGetty images

Set in 1012pt Bembo by SPi Global Pondicherry india

1 2016

Bioethics

An Anthology

THiRD EDiTiON

Edited by

Helga Kuhse Udo Schuumlklenk and Peter Singer

This third edition first published 2016Editorial material and organization copy 2016 John Wiley amp Sons inc

Edition history Blackwell Publishing Ltd (1e 1999 and 2e 2006)

Registered OfficeJohn Wiley amp Sons Ltd The Atrium Southern Gate Chichester West Sussex PO19 8SQ UK

Editorial Offices350 Main Street Malden MA 02148‐5020 USA9600 Garsington Road Oxford OX4 2DQ UKThe Atrium Southern Gate Chichester West Sussex PO19 8SQ UK

For details of our global editorial offices for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at wwwwileycomwiley‐blackwell

The right of Helga Kuhse Udo Schuumlklenk and Peter Singer to be identified as the authors of the editorial material in this work has been asserted in accordance with the UK Copyright Designs and Patents Act 1988

All rights reserved No part of this publication may be reproduced stored in a retrieval system or transmitted in any form or by any means electronic mechanical photocopying recording or otherwise except as permitted by the UK Copyright Designs and Patents Act 1988 without the prior permission of the publisher

Wiley also publishes its books in a variety of electronic formats Some content that appears in print may not be available in electronic books

Designations used by companies to distinguish their products are often claimed as trademarks All brand names and product names used in this book are trade names service marks trademarks or registered trademarks of their respective owners The publisher is not associated with any product or vendor mentioned in this book

Limit of LiabilityDisclaimer of Warranty While the publisher and authors have used their best efforts in preparing this book they make no representations or warranties with respect to the accuracy or completeness of the contents of this book and specifically disclaim any implied warranties of merchantability or fitness for a particular purpose it is sold on the understanding that the publisher is not engaged in rendering professional services and neither the publisher nor the author shall be liable for damages arising herefrom if professional advice or other expert assistance is required the services of a competent professional should be sought

Library of Congress Cataloging‐in‐Publication data is available for this title

9781118941508 [paperback]

A catalogue record for this book is available from the British Library

Cover image Gustav Klimt designs for The Stoclet Frieze 1905ndash1909 Austrian Museum for Applied Art Vienna Photo by Fine Art imagesHeritage imagesGetty images

Set in 1012pt Bembo by SPi Global Pondicherry india

1 2016

This third edition first published 2016Editorial material and organization copy 2016 John Wiley amp Sons inc

Edition history Blackwell Publishing Ltd (1e 1999 and 2e 2006)

Registered OfficeJohn Wiley amp Sons Ltd The Atrium Southern Gate Chichester West Sussex PO19 8SQ UK

Editorial Offices350 Main Street Malden MA 02148‐5020 USA9600 Garsington Road Oxford OX4 2DQ UKThe Atrium Southern Gate Chichester West Sussex PO19 8SQ UK

For details of our global editorial offices for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at wwwwileycomwiley‐blackwell

The right of Helga Kuhse Udo Schuumlklenk and Peter Singer to be identified as the authors of the editorial material in this work has been asserted in accordance with the UK Copyright Designs and Patents Act 1988

All rights reserved No part of this publication may be reproduced stored in a retrieval system or transmitted in any form or by any means electronic mechanical photocopying recording or otherwise except as permitted by the UK Copyright Designs and Patents Act 1988 without the prior permission of the publisher

Wiley also publishes its books in a variety of electronic formats Some content that appears in print may not be available in electronic books

Designations used by companies to distinguish their products are often claimed as trademarks All brand names and product names used in this book are trade names service marks trademarks or registered trademarks of their respective owners The publisher is not associated with any product or vendor mentioned in this book

Limit of LiabilityDisclaimer of Warranty While the publisher and authors have used their best efforts in preparing this book they make no representations or warranties with respect to the accuracy or completeness of the contents of this book and specifically disclaim any implied warranties of merchantability or fitness for a particular purpose it is sold on the understanding that the publisher is not engaged in rendering professional services and neither the publisher nor the author shall be liable for damages arising herefrom if professional advice or other expert assistance is required the services of a competent professional should be sought

Library of Congress Cataloging‐in‐Publication data is available for this title

9781118941508 [paperback]

A catalogue record for this book is available from the British Library

Cover image Gustav Klimt designs for The Stoclet Frieze 1905ndash1909 Austrian Museum for Applied Art Vienna Photo by Fine Art imagesHeritage imagesGetty images

Set in 1012pt Bembo by SPi Global Pondicherry india

1 2016

Contents

Acknowledgments xii

Introduction 1

Part I Abortion 9

Introduction 11

1 Abortion and Health Care Ethics 15John Finnis

2 Abortion and Infanticide 23Michael Tooley

3 A Defense of Abortion 38Judith Jarvis Thomson

4 Why Abortion Is Immoral 49Don Marquis

Part II Issues in Reproduction 61

Introduction 63

Assisted Reproduction 69

5 Multiple Gestation and Damaged Babies Godrsquos Will or Human Choice 71Gregory Pence

6 Assisted Reproduction in Same Sex Couples 74Dorothy A Greenfeld and Emre Seli

7 Rights Interests and Possible People 86Derek Parfit

8 The Ethics of Uterus Transplantation 91Ruby Catsanos Wendy Rogers and Mianna Lotz

Prenatal Screening Sex Selection and Cloning 103

9 Genetics and Reproductive Risk Can Having Children Be Immoral 105Laura M Purdy

vi contents

10 Prenatal Diagnosis and Selective Abortion A Challenge to Practice and Policy 112Adrienne Asch

11 Genetic Technology A Threat to Deafness 127Ruth Chadwick and Mairi Levitt

12 Sex Selection and Preimplantation Genetic Diagnosis The Ethics Committee of the American Society of Reproductive Medicine 136

13 Sex Selection and Preimplantation Diagnosis A Response to the Ethics Committee of the American Society of Reproductive Medicine 141Julian Savulescu and Edgar Dahl

14 Conception to Obtain Hematopoietic Stem Cells 144John A Robertson Jeffrey P Kahn and John E Wagner

15 Why We Should Not Permit Embryos to Be Selected as Tissue Donors 152David King

16 The Moral Status of the Cloning of Humans 156Michael Tooley

Part III Genetic Manipulation 173

Introduction 175

17 Questions about Some Uses of Genetic Engineering 177Jonathan Glover

18 The Moral Significance of the TherapyndashEnhancement Distinction in Human Genetics 189David B Resnik

19 Should We Undertake Genetic Research on Intelligence 199Ainsley Newson and Robert Williamson

20 In Defense of Posthuman Dignity 208Nick Bostrom

Part IV Life and Death Issues 215

Introduction 217

21 The Sanctity of Life 225Jonathan Glover

22 Declaration on Euthanasia 235Sacred Congregation for the Doctrine of the Faith

Killing and Letting Die 241

23 The Morality of Killing A Traditional View 243Germain Grisez and Joseph M Boyle Jr

24 Active and Passive Euthanasia 248James Rachels

25 Is Killing No Worse Than Letting Die 252Winston Nesbitt

Contents vii

26 Why Killing is Not Always Worse ndash and Sometimes Better ndash Than Letting Die 257Helga Kuhse

27 Moral Fictions and Medical Ethics 261Franklin G Miller Robert D Truog and Dan W Brock

Severely Disabled Newborns 271

28 When Care Cannot Cure Medical Problems in Seriously Ill Babies 273Neil Campbell

29 The Abnormal Child Moral Dilemmas of Doctors and Parents 285R M Hare

30 Right to Life of Handicapped 290Alison Davis

31 Conjoined Twins Embodied Personhood and Surgical Separation 292Christine Overall

Brain Death 305

32 A Definition of Irreversible Coma 307Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death

33 Are Recent Defences of the Brain Death Concept Adequate 312Ari Joffe

34 Is the Sanctity of Life Ethic Terminally Ill 321Peter Singer

Advance Directives 331

35 Life Past Reason 333Ronald Dworkin

36 Dworkin on Dementia Elegant Theory Questionable Policy 341Rebecca Dresser

Voluntary Euthanasia and Medically Assisted Suicide 351

37 The Note 353Chris Hill

38 When Self‐Determination Runs Amok 357Daniel Callahan

39 When Abstract Moralizing Runs Amok 362John Lachs

40 Trends in End‐of‐Life Practices Before and After the Enactment of the Euthanasia Law in the Netherlands from 1990 to 2010 A Repeated Cross‐Sectional Survey 366Bregje D Onwuteaka‐Philipsen Arianne Brinkman‐Stoppelenburg Corine Penning Gwen J F de Jong‐Krul Johannes J M van Delden and Agnes van der Heide

41 Euthanasia in the Netherlands What Lessons for Elsewhere 377Bernard Lo

viii contents

Part V Resource Allocation 381

Introduction 383

42 Rescuing Lives Canrsquot We Count 387Paul T Menzel

43 Should Alcoholics Compete Equally for Liver Transplantation 390Alvin H Moss and Mark Siegler

44 The Value of Life 397John Harris

45 Bubbles under the Wallpaper Healthcare Rationing and Discrimination 406Nick Beckstead and Toby Ord

Part VI Obtaining Organs 413

Introduction 415

46 Organ Donation and Retrieval Whose Body Is It Anyway 417Eike‐Henner W Kluge

47 The Case for Allowing Kidney Sales 421Janet Radcliffe‐Richards A S Daar R D Guttmann R Hoffenberg I Kennedy M Lock R A Sells N Tilney and for the International Forum for Transplant Ethics

48 Ethical Issues in the Supply and Demand of Human Kidneys 425Debra Satz

49 The Survival Lottery 437John Harris

Part VII Experimentation with Human Participants 443

Introduction 445

Human Participants 449

50 Ethics and Clinical Research 451Henry K Beecher

51 Equipoise and the Ethics of Clinical Research 459Benjamin Freedman

52 The Patient and the Public Good 466Samuel Hellman

53 Scientific Research Is a Moral Duty 471John Harris

54 Participation in Biomedical Research Is an Imperfect Moral Duty A Response to John Harris 483Sandra Shapshay and Kenneth D Pimple

Contents ix

55 Unethical Trials of Interventions to Reduce Perinatal Transmission of the Human Immunodeficiency Virus in Developing Countries 489Peter Lurie and Sidney M Wolfe

56 Wersquore Trying to Help Our Sickest People Not Exploit Them 495Danstan Bagenda and Philippa Musoke‐Mudido

57 Medical Researchersrsquo Ancillary Clinical Care Responsibilities 497Leah Belsky and Henry S Richardson

Human Embryos ndash Stem Cells 503

58 President Discusses Stem Cell Research 505George W Bush

59 Killing Embryos for Stem Cell Research 508Jeff McMahan

Part VIII Experimentation with Animals 521

Introduction 523

60 Duties towards Animals 527Immanuel Kant

61 A Utilitarian View 529Jeremy Bentham

62 All Animals Are Equal 530Peter Singer

63 Vivisection Morals and Medicine An Exchange 540R G Frey and Sir William Paton

Part IX Public Health Issues 551

Introduction 553

64 Ethics and Infectious Disease 555Michael J Selgelid

65 Rethinking Mandatory HIV Testing during Pregnancy in Areas with High HIV Prevalence Rates Ethical and Policy Issues 565Udo Schuumlklenk and Anita Kleinsmidt

66 Mandatory HIV Testing in Pregnancy Is There Ever a Time 572Russell Armstrong

67 XDR‐TB in South Africa No Time for Denial or Complacency 582Jerome Amir Singh Ross Upshur and Nesri Padayatchi

x contents

Part X Ethical Issues in the Practice of Healthcare 591

Introduction 593

Confidentiality 597

68 Confidentiality in Medicine A Decrepit Concept 599Mark Siegler

69 The Duty to Warn and Clinical Ethics Legal and Ethical Aspects of Confidentiality and HIVAIDS 603Christian Saumlfken and Andreas Frewer

Truth-Telling 611

70 On a Supposed Right to Lie from Altruistic Motives 613Immanuel Kant

71 Should Doctors Tell the Truth 615Joseph Collins

72 On Telling Patients the Truth 621Roger Higgs

Informed Consent and Patient Autonomy 629

73 On Liberty 631John Stuart Mill

74 From Schloendorff v NewYork Hospital 634Justice Benjamin N Cardozo

75 Informed Consent Its History Meaning and Present Challenges 635Tom L Beauchamp

76 The DoctorndashPatient Relationship in Different Cultures 642Ruth Macklin

77 Amputees by Choice 654Carl Elliott

78 Rational Desires and the Limitation of Life‐Sustaining Treatment 665Julian Savulescu

79 The Nocebo Effect of Informed Consent 683Shlomo Cohen

Part XI Special Issues Facing Nurses 693

Introduction 695

80 The Relation of the Nurse to the Doctor and the Doctor to the Nurse 699Sarah E Dock

81 In Defense of the Traditional Nurse 700Lisa H Newton

Contents xi

82 Patient Autonomy and Medical Paternity Can Nurses Help Doctors to Listen to Patients 708Sarah Breier

83 Health and Human Rights Advocacy Perspectives from a Rwandan Refugee Camp 718Carol Pavlish Anita Ho and Ann‐Marie Rounkle

Part XII Neuroethics 729

Introduction 731

84 Neuroethics An Agenda for Neuroscience and Society 733Jonathan D Moreno

85 How Electrical Brain Stimulation Can Change the Way We Think 741Sally Adee

86 Neuroethics Ethics and the Sciences of the Mind 744Neil Levy

87 Freedom of Memory Today 749Adam Kolber

88 Towards Responsible Use of Cognitive‐Enhancing Drugs by the Healthy 753Henry Greely Barbara Sahakian John Harris Ronald C Kessler Michael Gazzaniga Philip Campbell and Martha J Farah

89 Engineering Love 760Julian Savulescu and Anders Sandberg

Index 762

Acknowledgments

The editor and publisher gratefully acknowledge the permission granted to reproduce the copyright material in this book

1 John Finnis ldquoAbortion and Health Care Ethicsrdquo pp 547ndash57 from Raanan Gillon (ed) Principles of Health Care Ethics Chichester John Wiley 1994 Reproduced with permission from John Wiley amp Sons

2 Michael Tooley ldquoAbortion and Infanticiderdquo pp 37ndash65 from Philosophy and Public Affairs 1 (1972) Reproduced with permission from John Wiley amp Sons

3 Judith Jarvis Thomson ldquoA Defense of Abortionrdquo pp 47ndash66 from Philosophy and Public Affairs 1 1 (1971) Reproduced with permission from John Wiley amp Sons

4 Don Marquis ldquoWhy Abortion Is Immoralrdquo Journal of Philosophy 86 4 (April 1989) 183ndash202

5 Gregory Pence ldquoMultiple Gestation and Damaged Babies Godrsquos Will or Human Choicerdquo This essay draws on ldquoThe McCaughey Septuplets Godrsquos Will or Human Choicerdquo pp 39ndash43 from Gregory Pence Brave New Bioethics Lanham MD Rowman amp Littlefield 2002 copy Gregory Pence 2002 Courtesy of G Pence

6 Dorothy A Greenfeld and Emre Seli ldquoAssisted Reproduction in Same Sex Couplesrdquo pp 289ndash301 from M V Sauer (ed) Principles of Oocyte and Embryo Donation Springer‐Verlag 2013 With kind permisshysion from Springer Science+Business Media

7 Derek Parfit ldquoRights Interests and Possible Peoplerdquo pp 369ndash75 from Samuel Gorovitz et al (eds) Moral

Problems in Medicine Englewood Cliffs NJ Prentice Hall 1976 Courtesy of D Parfit

8 Ruby Catsanos Wendy Rogers and Mianna Lotz ldquoThe Ethics of Uterus Transplantationrdquo pp 65ndash73 from Bioethics 27 2 (2013) Reproduced by permission of John Wiley amp Sons

9 Laura M Purdy ldquoGenetics and Reproductive Risk Can Having Children be Immoralrdquo pp 39ndash49 from Reproducing Persons Issues in Feminist Bioethics Ithaca NY Cornell University Press 1996 Reproduced with permission from Cornell University Press

10 Adrienne Asch ldquoPrenatal Diagnosis and Selective Abortion A Challenge to Practice and Policyrdquo pp 1649ndash57 from American Journal of Public Health 89 11 (1999) Reproduced with permisshysion from American Public Health Association

11 Ruth Chadwick and Mairi Levitt ldquoGenetic Technology A Threat to Deafnessrdquo pp 209ndash15 from Medicine Healthcare and Philosophy 1 (1998) With kind permission from Springer Science+ Business Media

12 The Ethics Committee of the American Society of Reproductive Medicine ldquoSex Selection and Preimplantation Genetic Diagnosisrdquo pp 595ndash8 from Fertility and Sterility 72 4 (October 1999) Reprinted with permission from Elsevier

13 Julian Savulescu and Edgar Dahl ldquoSex Selection and Preimplantation Diagnosis A Response to the Ethics Committee of the American Society of Reproductive Medicinerdquo pp 1879ndash80 from Human Reproduction 15 9 (2000) By permission of Oxford University Press

Acknowledgments xiii

14 John A Robertson Jeffrey P Kahn and John E Wagner ldquoConception to Obtain Hematopoietic Stem Cellsrdquo pp 34ndash40 from Hastings Center Report 32 3 (MayJune 2002) Reproduced with permission from John Wiley amp Sons

15 David King ldquoWhy We Should Not Permit Embryos to Be Selected as Tissue Donorsrdquo pp 13ndash16 from The Bulletin of Medical Ethics 190 (August 2003) Copyright copy RSM Press 2003 Reproduced by permission of SAGE Publications Ltd London Los Angeles New Delhi Singapore and Washington DC

16 Michael Tooley ldquoThe Moral Status of the Cloning of Humansrdquo pp 67ndash101 from James M Humber and Robert I Almeder (eds) Human Cloning Totowa NJ Humana Press 1998 With kind permission from Springer Science+Business Media

17 Jonathan Glover ldquoQuestions about Some Uses of Genetic Engineeringrdquo pp 25ndash33 33ndash6 42ndash3 and 45ndash53 from What Sort of People Should There Be Harmondsworth Penguin Books 1984 Reproshyduced by permission of Penguin Books Ltd

18 David B Resnik ldquoThe Moral Significance of the TherapyndashEnhancement Distinction in Human Geneticsrdquo pp 365ndash77 from Cambridge Quarterly of Healthcare Ethics 9 3 (Summer 2000) copy Cambridge University Press Reproduced with permission

19 Ainsley Newson and Robert Williamson ldquoShould We Undertake Genetic Research on Intelligencerdquo pp 327ndash42 from Bioethics 13 34 (1999) Reproduced with permission from John Wiley amp Sons

20 Nick Bostrom ldquoIn Defense of Posthuman Dignityrdquo pp 202ndash14 from Bioethics 19 3 (2005) Reproduced with permission from John Wiley amp Sons

21 Jonathan Glover ldquoThe Sanctity of Liferdquo pp 39ndash59 from Causing Death and Lives London Pelican 1977 Reproduced by permission of Penguin Books Ltd

22 Sacred Congregation for the Doctrine of the Faith ldquoDeclaration on Euthanasiardquo Vatican City 1980

23 Germain Grisez and Joseph M Boyle Jr ldquoThe Morality of Killing A Traditional Viewrdquo

pp 381ndash419 from Life and Death with Liberty and Justice A Contribution to the Euthanasia Debate Notre Dame IN University of Notre Dame Press 1971

24 James Rachels ldquoActive and Passive Euthanasiardquo pp 78ndash80 from New England Journal of Medicine 292 (1975) Copyright copy 1975 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

25 Winston Nesbitt ldquoIs Killing No Worse Than Letting Dierdquo pp 101ndash5 from Journal of Applied Philosophy 12 1 (1995) Reproduced with permission from John Wiley amp Sons

26 Helga Kuhse ldquoWhy Killing Is Not Always Worse ndash and Sometimes Better ndash Than Letting Dierdquo pp 371ndash4 from Cambridge Quarterly of Healthcare 7 4 (1998) copy Cambridge University Press Reproduced with permission

27 Franklin G Miller Robert D Truog and Dan W Brock ldquoMoral Fictions and Medical Ethicsrdquo pp 453ndash60 from Bioethics 24 9 (2010) Reproduced with permission from John Wiley amp Sons

28 Neil Campbell ldquoWhen Care Cannot Cure Medical Problems in Seriously Ill Babiesrdquo pp 327ndash44 from F K Beller and R F Weir (eds) The Beginning of Human Life Dordrecht Kluwer Academic Publishers 1994 With kind pershymission from Springer Science+Business Media

29 R M Hare ldquoThe Abnormal Child Moral Dilemmas of Doctors and Parentsrdquo Reprinted in Essays on Bioethics Oxford Clarendon Press 1993 pp185ndash91 Courtesy of the Estate of R M Hare

30 Alison Davis ldquoRight to Life of Handicappedrdquo p 181 from Journal of Medical Ethics 9 (1983) Reproduced with permission from BMJ Publishing Group

31 Christine Overall ldquoConjoined Twins Embodied Personhood and Surgical Separationrdquo pp 69ndash84 from L Tessman (ed) Feminist Ethics and Social and Political Philosophy Theorizing the Non‐Ideal Springer 2009 With kind permission from Springer Science+Business Media

32 Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death ldquolsquoA Definition of Irreversible Comarsquo Report to Examine the Definition of Brain

xiv acknowledgments

Deathrdquo pp 85ndash8 from Journal of the American Medical Association 205 6 (August 1968) Copyright copy 1968 American Medical Association All rights reserved

33 Ari Joffe ldquoAre Recent Defences of the Brain Death Concept Adequaterdquo pp 47ndash53 from Bioethics 24 2 (February 2010) Reproduced with permission from John Wiley amp Sons

34 Peter Singer ldquoIs the Sanctity of Life Ethic Terminally Illrdquo pp 307ndash43 from Bioethics 9 34 (1995) Reproduced with permission from John Wiley amp Sons

35 Ronald Dworkin ldquoLife Past Reasonrdquo pp 218ndash29 from Lifersquos Dominion An Argument about Abortion Euthanasia and Individual Freedom New York Knopf 1993 Copyright copy 1993 by Ronald Dworkin Used by permission of Alfred A Knopf an imprint of the Knopf Doubleday Publishing Group a division of Random House LLC All rights reserved

36 Rebecca Dresser ldquoDworkin on Dementia Elegant Theory Questionable Policyrdquo pp 32ndash8 from Hastings Center Report 25 6 (NovemberDecember 1995) Reproduced with permission from John Wiley amp Sons

37 Chris Hill ldquoThe Noterdquo pp 9ndash17 from Helga Kuhse (ed) Willing to Listen Wanting to Die Ringwood Australia Penguin Books 1994

38 Daniel Callahan ldquoWhen Self‐Determination Runs Amokrdquo pp 52ndash5 from Hastings Center Report 22 2 (MarchApril 1992) Reproduced with permission from John Wiley amp Sons

39 John Lachs ldquoWhen Abstract Moralizing Runs Amokrdquo pp 10ndash13 from The Journal of Clinical Ethics 5 1 (Spring 1994) Copyright JCE

40 Bregje D Onwuteaka‐Philipsen et al ldquoTrends in End‐Of‐Life Practices Before and After the Enactment of the Euthanasia Law in the Netherlands from 1990 to 2010 A Repeated Cross‐Sectional Surveyrdquo pp 908ndash15 from The Lancet 380 9845 (2012) Reprinted from The Lancet with permission from Elsevier

41 Bernard Lo ldquoEuthanasia in the Netherlands What Lessons for Elsewhererdquo pp 869ndash70 from The Lancet 380 (September 8 2012) Copyright 2012 Reprinted from The Lancet with permisshysion from Elsevier

42 Paul T Menzel ldquoRescuing Lives Canrsquot We Countrdquo pp 22ndash3 from Hastings Center Report 24 1 (1994) Reproduced with permission from John Wiley amp Sons

43 Alvin H Moss and Mark Siegler ldquoShould Alcoholics Compete Equally for Liver Transshyplantationrdquo pp 1295ndash8 from Journal of the American Medical Association 265 10 (1991) Copyright copy 1991 American Medical Association All rights reserved

44 John Harris ldquoThe Value of Liferdquo pp 87ndash102 from The Value of Life London Routledge 1985 Copyright 1985 Routledge Reproduced by permission of Taylor amp Francis Books UK

45 Nick Beckstead and Toby Ord ldquoBubbles under the Wallpaper Healthcare Rationing and Disshycriminationrdquo a paper presented to the confershyence ldquoValuing Livesrdquo New York University March 5 2011 copy Nick Beckstead and Toby Ord reprinted by permission of the authors This paper is published here for the first time but draws on Nick Beckstead and Toby Ord ldquoRationing and Rationality The Cost of Avoiding Discriminationrdquo in N Eyal et al (eds) Inequalities in Health Concepts Measures and Ethics Oxford Oxford University Press 2013 pp 232ndash9 By permission of Oxford University Press

46 Eike‐Henner W Kluge ldquoOrgan Donation and Retrieval Whose Body Is It Anywayrdquo copy 1999 by Eike‐Henner W Kluge

47 Janet Radcliffe‐Richards et al ldquoThe Case for Allowing Kidney Salesrdquo pp 1950ndash2 from The Lancet 351 9120 (June 27 1998) Reprinted with permission from Elsevier

48 Debra Satz ldquoEthical Issues in the Supply and Demand of Human Kidneysrdquo pp 189ndash206 from Why Some Things Should Not Be for Sale The Moral Limits of Markets New York Oxford University Press 2010 ch 9 based on an article from Proceedings of the Aristotelian Society Reprinted by courtesy of the Editor of Proceedings of the Aristotelian Society copy 2010

49 John Harris ldquoThe Survival Lotteryrdquo pp 81ndash7 from Philosophy 50 (1975) copy Royal Institute of Philosophy published by Cambridge University Press Reproduced with permission

Acknowledgments xv

50 Henry K Beecher ldquoEthics and Clinical Researchrdquo pp 1354ndash60 from New England Journal of Medicine 274 24 (June 1966) Copyright copy 1996 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

51 Benjamin Freedman ldquoEquipoise and the Ethics of Clinical Researchrdquo pp 141ndash5 from New England Journal of Medicine 317 3 (July 1987) Copyright copy 1987 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

52 Samuel Hellman ldquoThe Patient and the Public Goodrdquo pp 400ndash2 from Nature Medicine 1 5 (1995) Reprinted by permission from Macmillan Publishers Ltd

53 John Harris ldquoScientific Research Is a Moral Dutyrdquo pp 242ndash8 from Journal of Medical Ethics 31 4 (2005) Reproduced with permission from BMJ Publishing Group

54 Sandra Shapshay and Kenneth D Pimple ldquoParticipation in Research Is an Imperfect Moral Duty A Response to John Harrisrdquo pp 414ndash17 from Journal of Medical Ethics 33 (2007) Reproduced with permission from BMJ Publishing Group

55 Peter Lurie and Sidney M Wolfe ldquoUnethical Trials of Interventions to Reduce Perinatal Transmission of the Human Immunodeficiency Virus in Developing Countriesrdquo pp 853ndash6 from New England Journal of Medicine 337 12 (September 1997) Copyright copy 1997 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

56 Danstan Bageda and Philippa Musoke‐Mudido ldquoWersquore Trying to Help Our Sickest People Not Exploit Themrdquo from The Washington Post September 28 1997 copy 1997 Washington Post Company All rights reserved Used by permisshysion and protected by the Copyright Laws of the United States The printing copying redistribushytion or retransmission of this Content without express written permission is prohibited

57 Leah Belsky and Henry S Richardson ldquoMedical Researchersrsquo Ancillary Clinical Care Respon sibilitiesrdquo pp 1494ndash6 from British

Medical Journal 328 (June 19 2004) Reproduced with permission from BMJ Publishing Group

58 George W Bush ldquoPresident Discusses Stem Cell Researchrdquo Office of the Press Secretary White House August 9 2001

59 Jeff McMahan ldquoKilling Embryos for Stem Cell Researchrdquo pp 170ndash89 from Metaphilosophy 38 23 (2007) Reproduced with permission from John Wiley amp Sons

60 Immanuel Kant ldquoDuties towards Animalsrdquo pp 239ndash41 from Lectures on Ethics trans Louis Infield London Methuen 1930 Copyright 1930 Methuen reproduced by permission of Taylor amp Francis Books UK

61 Jeremy Bentham ldquoA Utilitarian Viewrdquo section XVIII IV from An Introduction to the Principles of Morals and Legislation First published c1820

62 Peter Singer ldquoAll Animals are Equalrdquo pp 103ndash16 from Philosophic Exchange 1 5 (1974) Center for Philosophic Exchange State University of New York Brockford NY 1974

63 R G Frey and Sir William Paton ldquoVivisection Morals and Medicine An Exchangerdquo pp 94ndash7 and 102ndash4 from Journal of Medical Ethics 9 (1983) Reproduced with permission from BMJ Publishing Group

64 Michael J Selgelid ldquoEthics and Infectious Diseaserdquo pp 272ndash89 from Bioethics 19 3 (2005) Reproduced with permission from John Wiley amp Sons

65 Udo Schuumlklenk and Anita Kleinsmidt ldquoRethinking Mandatory HIV Testing during Pregnancy in Areas with High HIV Prevalence Rates Ethical and Policy Issuesrdquo pp 1179ndash83 from American Journal of Public Health 97 7 (2007) Reproduced with permission from American Public Health Association

66 Russell Armstrong ldquoMandatory HIV Testing in Pregnancy Is There Ever a Timerdquo pp 1ndash10 from Developing World Bioethics 8 1 (2008) Reproduced with permission from John Wiley amp Sons

67 Jerome Amir Singh Ross Upshur and Nesri Padayatchi ldquoXDR‐TB in South Africa No Time for Denial or Complacencyrdquo PLoS Med 4 1 (2007) e50 doi101371journalpmed0040050 Copyright copy 2007 Singh et al

xvi acknowledgments

68 Mark Siegler ldquoConfidentiality in Medicine A Decrepit Conceptrdquo pp 1518ndash21 from New England Journal of Medicine 307 24 (December 1982) Copyright copy 1982 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

69 Christian Saumlfken and Andreas Frewer ldquoThe Duty to Warn and Clinical Ethics Legal and Ethical Aspects of Confidentiality and HIVAIDSrdquo pp 313ndash326 from HEC Forum 19 4 (2007) With kind permission from Springer Science+Business Media

70 Immanuel Kant ldquoOn a Supposed Right to Lie from Altruistic Motivesrdquo pp 361ndash3 from Critique of Practical Reason and Other Works on the Theory of Ethics 6th edition trans T K Abbott London 1909 This essay was first published in a Berlin periodical in 1797

71 Joseph Collins ldquoShould Doctors Tell the Truthrdquo pp 320ndash6 from Harperrsquos Monthly Magazine 155 (August 1927) Copyright copy 1927 Harperrsquos Magazine All rights reserved Reproduced from the August issue by special permission

72 Roger Higgs ldquoOn Telling Patients the Truthrdquo pp 186ndash202 and 232ndash3 from Michael Lockwood (ed) Moral Dilemmas in Modern Medicine Oxford Oxford University Press 1985 By permission of Oxford University Press

73 John Stuart Mill ldquoOn Libertyrdquo first published in 1859

74 Justice Benjamin N Cardozo Judgment from Schloendorff v New York Hospital (1914) p 526 from Jay Katz (ed) Experimentation with Human Beings The Authority of the Investigator Subject Professions and State in the Human Experimentation Process New York Russell Sage Foundation 1972 Reproduced with permission of Russell Sage Foundation

75 Tom L Beauchamp ldquoInformed Consent Its History Meaning and Present Challengesrdquo pp 515ndash23 from Cambridge Quarterly of Health Care Ethics 20 4 (2011) copy Royal Institute of Philosophy published by Cambridge University Press Reproduced with permission from Cambridge University Press and T Beauchamp

76 Ruth Macklin ldquoThe DoctorndashPatient Relationshyship in Different Culturesrdquo pp 86ndash107 from

Against Relativism Cultural Diversity and the Search of Ethical Universals in Medicine copy 1999 by Oxford University Press Inc By permission of Oxford University Press USA

77 Carl Elliott ldquoAmputees by Choicerdquo pp 208ndash10 210ndash15 219ndash23 227ndash31 234ndash6 323ndash6 from Better Than Well American Medicine Meets the American Dream New York and London WW Norton 2003 Copyright copy 2003 by Carl Elliott Used by permission of W W Norton amp Company Inc

78 Julian Savulescu ldquoRational Desires and the Limishytation of Life‐Sustaining Treatmentrdquo pp 191ndash 222 from Bioethics 8 3 (1994) Reproduced with permission from John Wiley amp Sons

79 Shlomo Cohen ldquoThe Nocebo Effect of Informed Consentrdquo pp 147ndash54 from Bioethics 28 3 (2014) Reproduced with permission from John Wiley amp Sons

80 Sarah E Dock ldquoThe Relation of the Nurse to the Doctor and the Doctor to the Nurserdquo p 394 (extract) from The American Journal of Nursing 17 5 (1917)

81 Lisa H Newton ldquoIn Defense of the Traditional Nurserdquo pp 348ndash54 from Nursing Outlook 29 6 (1981) Copyright Elsevier 1981

82 Sarah Breier ldquoPatient Autonomy and Medical Paternity Can Nurses Help Doctors to Listen to Patientsrdquo pp 510ndash21 from Nursing Ethics 8 6 (2001) Reproduced with permission from Sage and S Breier

83 Carol Pavlish Anita Ho and Ann‐Marie Rounkle ldquoHealth and Human Rights Advocacy Perspectives from a Rwandan Refugee Camprdquo pp 538ndash49 from Nursing Ethics 19 4 (2012) Copyright copy 2012 by SAGE Publications Reprinted by Permission of SAGE

84 Jonathan D Moreno ldquoNeuroethics An Agenda for Neuroscience and Societyrdquo pp 149ndash53 from Nature Reviews 4 (February 2003)Reprinted by permission from Macmillan Publishers Ltd

85 Sally Adee ldquoHow Electrical Brain Stimulation Can Change the Way We Thinkrdquo The Week March 30 2012

86 Neil Levy ldquoNeuroethics Ethics and the Sciences of the Mindrdquo pp 69ndash74 (extract) from Philosophy

Acknowledgments xvii

Compass 4 10 (2009) pp 69ndash81 Reproduced with permission from John Wiley amp Sons

87 Adam Kolber ldquoFreedom of Memory Todayrdquo pp 145ndash8 from Neuroethics 1 (2008) With kind permission from Springer Science+Business Media

88 Henry Greely and Colleagues ldquoTowards Responsible Use of Cognitive‐Enhancing Drugs

by the Healthyrdquo pp 702ndash5 from Nature 456 (December 11 2008) Reprinted by permission from Macmillan Publishers Ltd

89 Julian Savulescu and Anders Sandberg ldquoEngineering LoverdquoldquoLove Machine Engineering Lifelong Romancerdquo pp 28ndash9 from New Scientist 2864 copy 2012 Reed Business Information ndash UK All rights reserved Distributed by Tribune Content Agency

Bioethics An Anthology Third Edition Edited by Helga Kuhse Udo Schuumlklenk and Peter Singer copy 2016 John Wiley amp Sons Inc Published 2016 by John Wiley amp Sons Inc

Introduction

The term ldquobioethicsrdquo was coined by Van Rensselaer Potter who used it to describe his proposal that we need an ethic that can incorporate our obligations not just to other humans but to the biosphere as a whole1 Although the term is still occasionally used in this sense of an ecological ethic it is now much more commonly used in the narrower sense of the study of ethical issues arising from the biological and medical sciences So understood bioethics has become a specialized although interdisciplinary area of study The essays included in this book give an indication of the range of issues which fall within its scope ndash but it is only an indication There are many other issues that we simply have not had the space to cover

Bioethics can be seen as a branch of ethics or more specifically of applied ethics For this reason some understanding of the nature of ethics is an essential preliminary to any serious study of bioethics The remainder of this introduction will seek to provide that understanding

One question about the nature of ethics is especially relevant to bioethics to what extent is reasoning or argument possible in ethics Many people assume without much thought that ethics is subjective The subjectivist holds that what ethical view we take is a matter of opinion or taste that is not amenable to argument But if ethics were a matter of taste why would we even attempt to argue about it If Helen says ldquoI like my coffee sweetenedrdquo whereas Paul says

ldquoI like my coffee unsweetenedrdquo there is not much point in Helen and Paul arguing about it The two statements do not contradict each other They can both be true But if Helen says ldquoDoctors should never assist their patients to dierdquo whereas Paul says ldquoSometimes doctors should assist their patients to dierdquo then Helen and Paul are disagreeing and there does seem to be a point in their trying to argue about the issue of physician‐assisted suicide

It seems clear that there is some scope for argument in ethics If I say ldquoIt is always wrong to kill a human beingrdquo and ldquoAbortion is not always wrongrdquo then I am committed to denying that abortion kills a human being Otherwise I have contradicted myself and in doing so I have not stated a coherent position at all So consistency at least is a requirement of any defensible ethical position and thus sets a limit to the subjectivity of ethical judgments The requirement of factual accuracy sets another limit In discussing issues in bioethics the facts are often complex But we cannot reach the right ethical decisions unless we are well‐informed about the relevant facts In this respect ethical decisions are unlike decisions of taste We can enjoy a taste without knowing what we are eating but if we assume that it is wrong to resuscitate a terminally ill patient against her wishes then we can-not know whether an instance of resuscitation was morally right or wrong without knowing something about the patientrsquos prognosis and whether the patient

2 introduction

has expressed any wishes about being resuscitated In that sense there is no equivalent in ethics to the immediacy of taste

Ethical relativism sometimes also known as cul-tural relativism is one step away from ethical sub-jectivism but it also severely limits the scope of ethical argument The ethical relativist holds that it is not individual attitudes that determine what is right or wrong but the attitudes of the culture in which one lives Herodotus tells how Darius King of Persia summoned the Greeks from the western shores of his kingdom before him and asked them how much he would have to pay them to eat their fathersrsquo dead bodies They were horrified by the idea and said they would not do it for any amount of money for it was their custom to cremate their dead Then Darius called upon Indians from the eastern frontiers of his kingdom and asked them what would make them willing to burn their fathersrsquo bodies They cried out and asked the King to refrain from mentioning so shocking an act Herodotus comments that each nation thinks its own customs best From here it is only a short step to the view that there can be no objective right or wrong beyond the bounds of onersquos own culture This view found increased support in the nine-teenth century as Western anthropologists came to know many different cultures and were impressed by ethical views very different from those that were standardly taken for granted in European society As a defense against the automatic assumption that Western morality is superior and should be imposed on ldquosavagesrdquo many anthropologists argued that since morality is relative to culture no culture can have any basis for regarding its morality as superior to any other culture

Although the motives with which anthropolo-gists put this view forward were admirable they may not have appreciated the implications of the position they were taking The ethical relativist maintains that a statement like ldquoIt is good to enslave people from another tribe if they are captured in warrdquo means simply ldquoIn my society the custom is to enslave people from another tribe if they are cap-tured in warrdquo Hence if one member of the society were to question whether it really was good to enslave people in these circumstances she could be

answered simply by demonstrating that this was indeed the custom ndash for example by showing that for many generations it had been done after every war in which prisoners were captured Thus there is no way for moral reformers to say that an accepted custom is wrong ndash ldquowrongrdquo just means ldquoin accord-ance with an accepted customrdquo

On the other hand when people from two different cultures disagree about an ethical issue then according to the ethical relativist there can be no resolution of the disagreement Indeed strictly there is no disagree-ment If the apparent dispute were over the issue just mentioned then one person would be saying ldquoIn my country it is the custom to enslave people from another tribe if they are captured in warrdquo and the other person would be saying ldquoIn my country it is not the custom to allow one human being to enslave anotherrdquo This is no more a disagreement than such statements as ldquoIn my country people greet each other by rubbing nosesrdquo and ldquoIn my country people greet each other by shaking handsrdquo If ethical relativism is true then it is impossible to say that one culture is right and the other is wrong Bearing in mind that some cultures have practiced slavery or the burning of widows on the funeral pyre of their husbands this is hard to accept

A more promising alternative to both ethical subjectivism and cultural relativism is universal pre-scriptivism an approach to ethics developed by the Oxford philosopher R M Hare Hare argues that the distinctive property of ethical judgments is that they are universalizable In saying this he means that if I make an ethical judgment I must be prepared to state it in universal terms and apply it to all relevantly similar situations By ldquouniversal termsrdquo Hare means those terms that do not refer to a particular individual Thus a proper name cannot be a universal term If for example I were to say ldquoEveryone should do what is in the interests of Mick Jaggerrdquo I would not be making a universal judgment because I have used a proper name The same would be true if I were to say that everyone must do what is in my interests because the personal pronoun ldquomyrdquo is here used to refer to a particular individual myself

It might seem that ruling out particular terms in this way does not take us very far After all one can always describe oneself in universal terms Perhaps

Introduction 3

I canrsquot say that everyone should do what is in my interests but I could say that everyone must do whatever is in the interests of people who hellip and then give a minutely detailed description of myself including the precise location of all my freckles The effect would be the same as saying that everyone should do what is in my interests because there would be no one except me who matches that description But Hare meets this problem very effectively by saying that to prescribe an ethical judgment universally means being prepared to pre-scribe it for all possible circumstances including hypothetical ones So if I were to say that everyone should do what is in the interests of a person with a particular pattern of freckles I must be prepared to prescribe that in the hypothetical situation in which I do not have this pattern of freckles but someone else does I should do what is in the interests of that person Now of course I may say that I should do that since I am confident that I shall never be in such a situation but this simply means that I am being dishonest I am not genuinely prescribing the principle universally

The effect of saying that an ethical judgment must be universalizable for hypothetical as well as actual circumstances is that whenever I make an ethical judgment I can be challenged to put myself in the position of the parties affected and see if I would still be able to accept that judgment Suppose for example that I own a small factory and the cheapest way for me to get rid of some waste is to pour it into a nearby river I do not take water from this river but I know that some villagers living downstream do and the waste may make them ill The requirement that ethical judgments should be universalizable will make it difficult for me to justify my conduct because if I imagine myself in the hypothetical situation of being one of the villagers rather than the factory‐owner I would not accept that the profits of the factory‐owner should outweigh the risk of adverse effects on my health and that of my children In this way Harersquos approach requires us to take into account the interests and preferences of all others affected by our actions Hence it allows for an element of reasoning in ethical deliberation

Since the rightness or wrongness of our actions will on this view depend on the way in which they

affect others Harersquos universal prescriptivism leads to a form of consequentialism ndash that is the view that the rightness of an action depends on its consequences The best‐known form of consequentialism is the clas-sical utilitarianism developed in the late eighteenth century by Jeremy Bentham and popularized in the nineteenth century by John Stuart Mill They held that an action is right if it leads to a greater surplus of happiness over misery than any possible alternative and wrong if it does not By ldquogreater surplus of happinessrdquo the classical utilitarians had in mind the idea of adding up all the pleasure or happiness that resulted from the action and subtracting from that total all the pain or misery to which the action gave rise Naturally in some circumstances it might be possible only to reduce misery and then the right action should be understood as the one that will result in less misery than any possible alternative

The utilitarian view is striking in many ways It puts forward a single principle that it claims can provide the right answer to all ethical dilemmas if only we can predict what the consequences of our actions will be It takes ethics out of the mysterious realm of duties and rules and bases ethical decisions on something that almost everyone understands and values Moreover utilitarianismrsquos single principle is applied universally without fear or favor Bentham said ldquoEach to count for one and none for more than onerdquo by which he meant that the happiness of a com-mon tramp counted for as much as that of a noble and the happiness of an African was no less important than that of a European

Many contemporary consequentialists agree with Bentham to the extent that they think the rightness or wrongness of an action must depend on its conse-quences but they have abandoned the idea that m aximizing net happiness is the ultimate goal Instead they argue that we should seek to bring about w hatever will satisfy the greatest number of desires or preference This variation which is known as ldquop reference utilitarianismrdquo does not regard anything as good except in so far as it is wanted or desired More intense or strongly held preferences would get more weight than weak preferences

Consequentialism offers one important answer to the question of how we should decide what is right and what is wrong but many ethicists reject it The

4 introduction

denial of this view was dramatically presented by Dostoevsky in The Karamazov Brothers

imagine that you are charged with building the edifice of human destiny the ultimate aim of which is to bring people happiness to give them peace and contentment at last but that in order to achieve this it is essential and unavoidable to torture just one little speck of creation that same little child beating her chest with her little fists and imagine that this edifice has to be erected on her unexpiated tears Would you agree to be the architect under those conditions Tell me honestly2

The passage suggests that some things are always wrong no matter what their consequences This has for most of Western history been the prevailing approach to morality at least at the level of what has been officially taught and approved by the institutions of Church and State The ten commandments of the Hebrew scriptures served as a model for much of the Christian era and the Roman Catholic Church built up an elaborate system of morality based on rules to which no exceptions were allowed

Another example of an ethic of rules is that of Immanuel Kant Kantrsquos ethic is based on his ldquocategori-cal imperativerdquo which he states in several distinct for-mulations One is that we must always act so that we can will the maxim of our action to be a universal law This can be interpreted as a form of Harersquos idea of universalizability which we have already encountered Another is that we must always treat other people as ends never as means While these formulations of the categorical imperative might be applied in various ways in Kantrsquos hands they lead to inviolable rules for example against making promises that we do not intend to keep Kant also thought that it was always wrong to tell a lie In response to a critic who sug-gested that this rule has exceptions Kant said that it would be wrong to lie even if someone had taken refuge in your house and a person seeking to murder him came to your door and asked if you knew where he was Modern Kantians often reject this hard-line approach to rules and claim that Kantrsquos categorical imperative did not require him to hold so strictly to the rule against lying

How would a consequentialist ndash for example a classical utilitarian ndash answer Dostoevskyrsquos challenge If answering honestly ndash and if one really could be certain

that this was a sure way and the only way of bringing lasting happiness to all the people of the world ndash utilitarians would have to say yes they would accept the task of being the architect of the happiness of the world at the cost of the childrsquos unexpiated tears For they would point out that the suffering of that child wholly undeserved as it is will be repeated a million‐fold over the next century for other children just as innocent who are victims of starvation disease and brutality So if this one child must be sacrificed to stop all this suffering then terrible as it is the child must be sacrificed

Fantasy apart there can be no architect of the hap-piness of the world The world is too big and complex a place for that But we may attempt to bring about less suffering and more happiness or satisfaction of preferences for people or sentient beings in specific places and circumstances Alternatively we might fol-low a set of principles or rules ndash which could be of varying degrees of rigidity or flexibility Where would such rules come from Kant tried to deduce them from his categorical imperative which in turn he had reached by insisting that the moral law must be based on reason alone without any content from our wants or desires But the problem with trying to deduce morality from reason alone has always been that it becomes an empty formalism that cannot tell us what to do To make it practical it needs to have some addi-tional content and Kantrsquos own attempts to deduce rules of conduct from his categorical imperative are unconvincing

Others following Aristotle have tried to draw on human nature as a source of moral rules What is good they say is what is natural to human beings They then contend that it is natural and right for us to seek certain goods such as knowledge friendship health love and procreation and unnatural and wrong for us to act contrary to these goods This ldquonatural lawrdquo ethic is open to criticism on several points The word ldquonaturalrdquo can be used both descriptively and evalua-tively and the two senses are often mixed together so that value judgments may be smuggled in under the guise of a description The picture of human nature presented by proponents of natural law ethics usually selects only those characteristics of our nature that the proponent considers desirable The fact that our species especially its male members frequently go to war and

Introduction 5

are also prone to commit individual acts of violence against others is no doubt just as much part of our nature as our desire for knowledge but no natural law theorist therefore views these activities as good More generally natural law theory has its origins in an Aristotelian idea of the cosmos in which everything has a goal or ldquoendrdquo which can be deduced from its nature The ldquoendrdquo of a knife is to cut the assumption is that human beings also have an ldquoendrdquo and we will flourish when we live in accordance with the end for which we are suited But this is a pre‐Darwinian view of nature Since Darwin we know that we do not exist for any purpose but are the result of natural selection operating on random mutations over millions of years Hence there is no reason to believe that living accord-ing to nature will produce a harmonious society let alone the best possible state of affairs for human beings

Another way in which it has been claimed that we can come to know what moral principles or rules we should follow is through our intuition In practice this usually means that we adopt conven-tionally accepted moral principles or rules perhaps with some adjustments in order to avoid inconsist-ency or arbitrariness On this view a moral theory should like a scientific theory try to match the data and the data that a moral theory must match is p rovided by our moral intuitions As in science if a plausible theory matches most but not all of the data then the anomalous data might be rejected on the grounds that it is more likely that there was an error in the procedures for gathering that particular set of data than that the theory as a whole is mis-taken But ultimately the test of a theory is its ability to explain the data The problem with applying this model of scientific justification to ethics is that the ldquodatardquo of our moral intuitions is unreliable not just at one or two specific points but as a whole Here the facts that cultural relativists draw upon are rele-vant (even if they do not establish that cultural rela-tivism is the correct response to it) Since we know that our intuitions are strongly influenced by such things as culture and religion they are ill‐suited to serve as the fixed points against which an ethical theory must be tested Even where there is cross‐cultural agreement there may be some aspects of our intuitions on which all cultures unjustifiably favor our own interests over those of others For

example simply because we are all human beings we may have a systematic bias that leads us to give an unjustifiably low moral status to nonhuman a nimals Or because in virtually all known human societies men have taken a greater leadership role than women the moral intuitions of all societies may not adequately reflect the interests of females

Some philosophers think that it is a mistake to base ethics on principles or rules Instead they focus on what it is to be a good person ndash or in the case of the problems with which this book is concerned perhaps on what it is to be a good nurse or doctor or researcher They seek to describe the virtues that a good person or a good member of the relevant profession should possess Moral education then consists of teaching these virtues and discussing how a virtuous person would act in specific situations The question is how-ever whether we can have a notion of what a virtuous person would do in a specific situation without making a prior decision about what it is right to do After all in any particular moral dilemma different virtues may be applicable and even a particular virtue will not always give unequivocal guidance For instance if a terminally ill patient repeatedly asks a nurse or doctor for assistance in dying what response best exemplifies the virtues of a healthcare professional There seems no answer to this question short of an inquiry into whether it is right or wrong to help a patient in such circumstances to die But in that case we seem bound in the end to come back to discuss-ing such issues as whether it is right to follow moral rules or principles or to do what will have the best consequences

In the late twentieth century some feminists offered new criticisms of conventional thought about ethics They argued that the approaches to ethics taken by the influential philosophers of the past ndash all of whom have been male ndash give too much emphasis to abstract principles and the role of reason and give too little attention to personal relationships and the part played by emotion One outcome of these criticisms has been the development of an ldquoethic of carerdquo which is not so much a single ethical theory as a cluster of ways of looking at ethics which put an attitude of c aring for others at the center and seek to avoid r eliance on abstract ethical principles The ethic of care has seemed especially applicable to the work of those

6 introduction

involved in direct patient care and has recently been taken up by a number of nursing theorists as offering a more suitable alternative to other ideas of ethics Not all feminists however support this development Some worry that the adoption of a ldquocarerdquo approach by nurses may reflect and even reinforce stereotypes of women as more emotional and less rational than men They also fear that it could lead to women continuing to carry a disproportionate burden of caring for others to the exclusion of adequately caring for themselves

In this discussion of ethics we have not mentioned anything about religion This may seem odd in view of the close connection that has often been made between religion and ethics but it reflects our belief that despite this historical connection ethics and reli-gion are fundamentally independent Logically ethics is prior to religion If religious believers wish to say that a deity is good or praise her or his creation or deeds they must have a notion of goodness that is independent of their conception of the deity and what she or he does Otherwise they will be saying that the deity is good and when asked what they mean by ldquogoodrdquo they will have to refer back to the deity saying perhaps that ldquogoodrdquo means ldquoin accord-ance with the wishes of the deityrdquo In that case sen-tences such as ldquoGod is goodrdquo would be a meaningless tautology ldquoGod is goodrdquo could mean no more than ldquoGod is in accordance with Godrsquos wishesrdquo As we have already seen there are ideas of what it is for something to be ldquogoodrdquo that are not rooted in any religious belief While religions typically encourage or instruct their followers to obey a particular ethical code it is obvious that others who do not follow any religion can also think and act ethically

To say that ethics is independent of religion is not to deny that theologians or other religious believers may have a role to play in bioethics Religious traditions often have long histories of dealing with ethical dilem-mas and the accumulation of wisdom and experience that they represent can give us valuable insights into particular problems But these insights should be subject to criticism in the way that any other proposals would be If in the end we accept them it is because we have judged them sound not because they are the utterances of a pope a rabbi a mullah or a holy person

Ethics is also independent of the law in the sense that the rightness or wrongness of an act cannot be

settled by its legality or illegality Whether an act is legal or illegal may often be relevant to whether it is right or wrong because it is arguably wrong to break the law other things being equal Many people have thought that this is especially so in a democracy in which everyone has a say in making the law Another reason why the fact that an act is illegal may be a rea-son against doing it is that the legality of an act may affect the consequences that are likely to flow from it If active voluntary euthanasia is illegal then doctors who practice it risk going to jail which will cause them and their families to suffer and also mean that they will no longer be able to help other patients This can be a powerful reason for not practicing voluntary euthanasia when it is against the law but if there is only a very small chance of the offense becoming known or being proved then the weight of this con-sequentialist reason against breaking the law is reduced accordingly Whether we have an ethical obligation to obey the law and if so how much weight should be given to it is itself an issue for ethical argument

Though ethics is independent of the law in the sense just specified laws are subject to evaluation from an ethical perspective Many debates in bioethics focus on questions about what practices should be allowed ndash for example should we allow research on stem cells taken from human embryos sex selection or cloning ndash and committees set up to advise on the ethical social and legal aspects of these questions often recommend legislation to prohibit the activity in question or to allow it to be practiced under some form of regulation Discussing a question at the level of law and public policy however raises somewhat different considerations than a discussion of personal ethics because the consequences of adopting a public policy generally have much wider ramifications than the consequences of a personal choice That is why some healthcare professionals feel justified in assisting a terminally ill patient to die while at the same time opposing the legalization of physician‐assisted suicide Paradoxical as this position may appear ndash and it is certainly open to criticism ndash it is not straightforwardly inconsistent

Naturally many of the essays we have selected reflect the times in which they were written Since bioethics often comments on developments in fast‐moving

Introduction 7

areas of medicine and the biological sciences the factual content of articles in bioethics can become obsolete quite rapidly In preparing this revised edition we have taken the opportunity to cover some new issues and to include some more recent writings We have for example included new mate-rial on genetic enhancement as well as on the use of embryonic human stem cells This edition of the anthology also includes new sections on ethical issues in public health and in the neurosciences Nevertheless an article that has dated in regard to its facts often makes ethical points that are still valid

or worth considering so we have not excluded older articles for this reason

Other articles are dated in a different way During the past few decades we have become more sensitive about the ways in which our language may exclude women or reflect our prejudices regarding race or sexuality We see no merit in trying to disguise past practices on such matters so we have not excluded otherwise valuable works in bioethics on these grounds If they are jar-ring to the modern reader that may be a salutary reminder of the extent to which we all are subject to the conventions and prejudices of our times

Notes

1 See Van Rensselaer Potter Bioethics Bridge to the Future (Englewood Cliffs NJ Prentice‐Hall 1971)

2 The Karamazov Brothers trans Ignat Avsey (Oxford Oxford University Press 1994) vol I part 2 bk 5 ch 4 First published in 1879

Abortion

Part I

vi contents

10 Prenatal Diagnosis and Selective Abortion A Challenge to Practice and Policy 112Adrienne Asch

11 Genetic Technology A Threat to Deafness 127Ruth Chadwick and Mairi Levitt

12 Sex Selection and Preimplantation Genetic Diagnosis The Ethics Committee of the American Society of Reproductive Medicine 136

13 Sex Selection and Preimplantation Diagnosis A Response to the Ethics Committee of the American Society of Reproductive Medicine 141Julian Savulescu and Edgar Dahl

14 Conception to Obtain Hematopoietic Stem Cells 144John A Robertson Jeffrey P Kahn and John E Wagner

15 Why We Should Not Permit Embryos to Be Selected as Tissue Donors 152David King

16 The Moral Status of the Cloning of Humans 156Michael Tooley

Part III Genetic Manipulation 173

Introduction 175

17 Questions about Some Uses of Genetic Engineering 177Jonathan Glover

18 The Moral Significance of the TherapyndashEnhancement Distinction in Human Genetics 189David B Resnik

19 Should We Undertake Genetic Research on Intelligence 199Ainsley Newson and Robert Williamson

20 In Defense of Posthuman Dignity 208Nick Bostrom

Part IV Life and Death Issues 215

Introduction 217

21 The Sanctity of Life 225Jonathan Glover

22 Declaration on Euthanasia 235Sacred Congregation for the Doctrine of the Faith

Killing and Letting Die 241

23 The Morality of Killing A Traditional View 243Germain Grisez and Joseph M Boyle Jr

24 Active and Passive Euthanasia 248James Rachels

25 Is Killing No Worse Than Letting Die 252Winston Nesbitt

Contents vii

26 Why Killing is Not Always Worse ndash and Sometimes Better ndash Than Letting Die 257Helga Kuhse

27 Moral Fictions and Medical Ethics 261Franklin G Miller Robert D Truog and Dan W Brock

Severely Disabled Newborns 271

28 When Care Cannot Cure Medical Problems in Seriously Ill Babies 273Neil Campbell

29 The Abnormal Child Moral Dilemmas of Doctors and Parents 285R M Hare

30 Right to Life of Handicapped 290Alison Davis

31 Conjoined Twins Embodied Personhood and Surgical Separation 292Christine Overall

Brain Death 305

32 A Definition of Irreversible Coma 307Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death

33 Are Recent Defences of the Brain Death Concept Adequate 312Ari Joffe

34 Is the Sanctity of Life Ethic Terminally Ill 321Peter Singer

Advance Directives 331

35 Life Past Reason 333Ronald Dworkin

36 Dworkin on Dementia Elegant Theory Questionable Policy 341Rebecca Dresser

Voluntary Euthanasia and Medically Assisted Suicide 351

37 The Note 353Chris Hill

38 When Self‐Determination Runs Amok 357Daniel Callahan

39 When Abstract Moralizing Runs Amok 362John Lachs

40 Trends in End‐of‐Life Practices Before and After the Enactment of the Euthanasia Law in the Netherlands from 1990 to 2010 A Repeated Cross‐Sectional Survey 366Bregje D Onwuteaka‐Philipsen Arianne Brinkman‐Stoppelenburg Corine Penning Gwen J F de Jong‐Krul Johannes J M van Delden and Agnes van der Heide

41 Euthanasia in the Netherlands What Lessons for Elsewhere 377Bernard Lo

viii contents

Part V Resource Allocation 381

Introduction 383

42 Rescuing Lives Canrsquot We Count 387Paul T Menzel

43 Should Alcoholics Compete Equally for Liver Transplantation 390Alvin H Moss and Mark Siegler

44 The Value of Life 397John Harris

45 Bubbles under the Wallpaper Healthcare Rationing and Discrimination 406Nick Beckstead and Toby Ord

Part VI Obtaining Organs 413

Introduction 415

46 Organ Donation and Retrieval Whose Body Is It Anyway 417Eike‐Henner W Kluge

47 The Case for Allowing Kidney Sales 421Janet Radcliffe‐Richards A S Daar R D Guttmann R Hoffenberg I Kennedy M Lock R A Sells N Tilney and for the International Forum for Transplant Ethics

48 Ethical Issues in the Supply and Demand of Human Kidneys 425Debra Satz

49 The Survival Lottery 437John Harris

Part VII Experimentation with Human Participants 443

Introduction 445

Human Participants 449

50 Ethics and Clinical Research 451Henry K Beecher

51 Equipoise and the Ethics of Clinical Research 459Benjamin Freedman

52 The Patient and the Public Good 466Samuel Hellman

53 Scientific Research Is a Moral Duty 471John Harris

54 Participation in Biomedical Research Is an Imperfect Moral Duty A Response to John Harris 483Sandra Shapshay and Kenneth D Pimple

Contents ix

55 Unethical Trials of Interventions to Reduce Perinatal Transmission of the Human Immunodeficiency Virus in Developing Countries 489Peter Lurie and Sidney M Wolfe

56 Wersquore Trying to Help Our Sickest People Not Exploit Them 495Danstan Bagenda and Philippa Musoke‐Mudido

57 Medical Researchersrsquo Ancillary Clinical Care Responsibilities 497Leah Belsky and Henry S Richardson

Human Embryos ndash Stem Cells 503

58 President Discusses Stem Cell Research 505George W Bush

59 Killing Embryos for Stem Cell Research 508Jeff McMahan

Part VIII Experimentation with Animals 521

Introduction 523

60 Duties towards Animals 527Immanuel Kant

61 A Utilitarian View 529Jeremy Bentham

62 All Animals Are Equal 530Peter Singer

63 Vivisection Morals and Medicine An Exchange 540R G Frey and Sir William Paton

Part IX Public Health Issues 551

Introduction 553

64 Ethics and Infectious Disease 555Michael J Selgelid

65 Rethinking Mandatory HIV Testing during Pregnancy in Areas with High HIV Prevalence Rates Ethical and Policy Issues 565Udo Schuumlklenk and Anita Kleinsmidt

66 Mandatory HIV Testing in Pregnancy Is There Ever a Time 572Russell Armstrong

67 XDR‐TB in South Africa No Time for Denial or Complacency 582Jerome Amir Singh Ross Upshur and Nesri Padayatchi

x contents

Part X Ethical Issues in the Practice of Healthcare 591

Introduction 593

Confidentiality 597

68 Confidentiality in Medicine A Decrepit Concept 599Mark Siegler

69 The Duty to Warn and Clinical Ethics Legal and Ethical Aspects of Confidentiality and HIVAIDS 603Christian Saumlfken and Andreas Frewer

Truth-Telling 611

70 On a Supposed Right to Lie from Altruistic Motives 613Immanuel Kant

71 Should Doctors Tell the Truth 615Joseph Collins

72 On Telling Patients the Truth 621Roger Higgs

Informed Consent and Patient Autonomy 629

73 On Liberty 631John Stuart Mill

74 From Schloendorff v NewYork Hospital 634Justice Benjamin N Cardozo

75 Informed Consent Its History Meaning and Present Challenges 635Tom L Beauchamp

76 The DoctorndashPatient Relationship in Different Cultures 642Ruth Macklin

77 Amputees by Choice 654Carl Elliott

78 Rational Desires and the Limitation of Life‐Sustaining Treatment 665Julian Savulescu

79 The Nocebo Effect of Informed Consent 683Shlomo Cohen

Part XI Special Issues Facing Nurses 693

Introduction 695

80 The Relation of the Nurse to the Doctor and the Doctor to the Nurse 699Sarah E Dock

81 In Defense of the Traditional Nurse 700Lisa H Newton

Contents xi

82 Patient Autonomy and Medical Paternity Can Nurses Help Doctors to Listen to Patients 708Sarah Breier

83 Health and Human Rights Advocacy Perspectives from a Rwandan Refugee Camp 718Carol Pavlish Anita Ho and Ann‐Marie Rounkle

Part XII Neuroethics 729

Introduction 731

84 Neuroethics An Agenda for Neuroscience and Society 733Jonathan D Moreno

85 How Electrical Brain Stimulation Can Change the Way We Think 741Sally Adee

86 Neuroethics Ethics and the Sciences of the Mind 744Neil Levy

87 Freedom of Memory Today 749Adam Kolber

88 Towards Responsible Use of Cognitive‐Enhancing Drugs by the Healthy 753Henry Greely Barbara Sahakian John Harris Ronald C Kessler Michael Gazzaniga Philip Campbell and Martha J Farah

89 Engineering Love 760Julian Savulescu and Anders Sandberg

Index 762

Acknowledgments

The editor and publisher gratefully acknowledge the permission granted to reproduce the copyright material in this book

1 John Finnis ldquoAbortion and Health Care Ethicsrdquo pp 547ndash57 from Raanan Gillon (ed) Principles of Health Care Ethics Chichester John Wiley 1994 Reproduced with permission from John Wiley amp Sons

2 Michael Tooley ldquoAbortion and Infanticiderdquo pp 37ndash65 from Philosophy and Public Affairs 1 (1972) Reproduced with permission from John Wiley amp Sons

3 Judith Jarvis Thomson ldquoA Defense of Abortionrdquo pp 47ndash66 from Philosophy and Public Affairs 1 1 (1971) Reproduced with permission from John Wiley amp Sons

4 Don Marquis ldquoWhy Abortion Is Immoralrdquo Journal of Philosophy 86 4 (April 1989) 183ndash202

5 Gregory Pence ldquoMultiple Gestation and Damaged Babies Godrsquos Will or Human Choicerdquo This essay draws on ldquoThe McCaughey Septuplets Godrsquos Will or Human Choicerdquo pp 39ndash43 from Gregory Pence Brave New Bioethics Lanham MD Rowman amp Littlefield 2002 copy Gregory Pence 2002 Courtesy of G Pence

6 Dorothy A Greenfeld and Emre Seli ldquoAssisted Reproduction in Same Sex Couplesrdquo pp 289ndash301 from M V Sauer (ed) Principles of Oocyte and Embryo Donation Springer‐Verlag 2013 With kind permisshysion from Springer Science+Business Media

7 Derek Parfit ldquoRights Interests and Possible Peoplerdquo pp 369ndash75 from Samuel Gorovitz et al (eds) Moral

Problems in Medicine Englewood Cliffs NJ Prentice Hall 1976 Courtesy of D Parfit

8 Ruby Catsanos Wendy Rogers and Mianna Lotz ldquoThe Ethics of Uterus Transplantationrdquo pp 65ndash73 from Bioethics 27 2 (2013) Reproduced by permission of John Wiley amp Sons

9 Laura M Purdy ldquoGenetics and Reproductive Risk Can Having Children be Immoralrdquo pp 39ndash49 from Reproducing Persons Issues in Feminist Bioethics Ithaca NY Cornell University Press 1996 Reproduced with permission from Cornell University Press

10 Adrienne Asch ldquoPrenatal Diagnosis and Selective Abortion A Challenge to Practice and Policyrdquo pp 1649ndash57 from American Journal of Public Health 89 11 (1999) Reproduced with permisshysion from American Public Health Association

11 Ruth Chadwick and Mairi Levitt ldquoGenetic Technology A Threat to Deafnessrdquo pp 209ndash15 from Medicine Healthcare and Philosophy 1 (1998) With kind permission from Springer Science+ Business Media

12 The Ethics Committee of the American Society of Reproductive Medicine ldquoSex Selection and Preimplantation Genetic Diagnosisrdquo pp 595ndash8 from Fertility and Sterility 72 4 (October 1999) Reprinted with permission from Elsevier

13 Julian Savulescu and Edgar Dahl ldquoSex Selection and Preimplantation Diagnosis A Response to the Ethics Committee of the American Society of Reproductive Medicinerdquo pp 1879ndash80 from Human Reproduction 15 9 (2000) By permission of Oxford University Press

Acknowledgments xiii

14 John A Robertson Jeffrey P Kahn and John E Wagner ldquoConception to Obtain Hematopoietic Stem Cellsrdquo pp 34ndash40 from Hastings Center Report 32 3 (MayJune 2002) Reproduced with permission from John Wiley amp Sons

15 David King ldquoWhy We Should Not Permit Embryos to Be Selected as Tissue Donorsrdquo pp 13ndash16 from The Bulletin of Medical Ethics 190 (August 2003) Copyright copy RSM Press 2003 Reproduced by permission of SAGE Publications Ltd London Los Angeles New Delhi Singapore and Washington DC

16 Michael Tooley ldquoThe Moral Status of the Cloning of Humansrdquo pp 67ndash101 from James M Humber and Robert I Almeder (eds) Human Cloning Totowa NJ Humana Press 1998 With kind permission from Springer Science+Business Media

17 Jonathan Glover ldquoQuestions about Some Uses of Genetic Engineeringrdquo pp 25ndash33 33ndash6 42ndash3 and 45ndash53 from What Sort of People Should There Be Harmondsworth Penguin Books 1984 Reproshyduced by permission of Penguin Books Ltd

18 David B Resnik ldquoThe Moral Significance of the TherapyndashEnhancement Distinction in Human Geneticsrdquo pp 365ndash77 from Cambridge Quarterly of Healthcare Ethics 9 3 (Summer 2000) copy Cambridge University Press Reproduced with permission

19 Ainsley Newson and Robert Williamson ldquoShould We Undertake Genetic Research on Intelligencerdquo pp 327ndash42 from Bioethics 13 34 (1999) Reproduced with permission from John Wiley amp Sons

20 Nick Bostrom ldquoIn Defense of Posthuman Dignityrdquo pp 202ndash14 from Bioethics 19 3 (2005) Reproduced with permission from John Wiley amp Sons

21 Jonathan Glover ldquoThe Sanctity of Liferdquo pp 39ndash59 from Causing Death and Lives London Pelican 1977 Reproduced by permission of Penguin Books Ltd

22 Sacred Congregation for the Doctrine of the Faith ldquoDeclaration on Euthanasiardquo Vatican City 1980

23 Germain Grisez and Joseph M Boyle Jr ldquoThe Morality of Killing A Traditional Viewrdquo

pp 381ndash419 from Life and Death with Liberty and Justice A Contribution to the Euthanasia Debate Notre Dame IN University of Notre Dame Press 1971

24 James Rachels ldquoActive and Passive Euthanasiardquo pp 78ndash80 from New England Journal of Medicine 292 (1975) Copyright copy 1975 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

25 Winston Nesbitt ldquoIs Killing No Worse Than Letting Dierdquo pp 101ndash5 from Journal of Applied Philosophy 12 1 (1995) Reproduced with permission from John Wiley amp Sons

26 Helga Kuhse ldquoWhy Killing Is Not Always Worse ndash and Sometimes Better ndash Than Letting Dierdquo pp 371ndash4 from Cambridge Quarterly of Healthcare 7 4 (1998) copy Cambridge University Press Reproduced with permission

27 Franklin G Miller Robert D Truog and Dan W Brock ldquoMoral Fictions and Medical Ethicsrdquo pp 453ndash60 from Bioethics 24 9 (2010) Reproduced with permission from John Wiley amp Sons

28 Neil Campbell ldquoWhen Care Cannot Cure Medical Problems in Seriously Ill Babiesrdquo pp 327ndash44 from F K Beller and R F Weir (eds) The Beginning of Human Life Dordrecht Kluwer Academic Publishers 1994 With kind pershymission from Springer Science+Business Media

29 R M Hare ldquoThe Abnormal Child Moral Dilemmas of Doctors and Parentsrdquo Reprinted in Essays on Bioethics Oxford Clarendon Press 1993 pp185ndash91 Courtesy of the Estate of R M Hare

30 Alison Davis ldquoRight to Life of Handicappedrdquo p 181 from Journal of Medical Ethics 9 (1983) Reproduced with permission from BMJ Publishing Group

31 Christine Overall ldquoConjoined Twins Embodied Personhood and Surgical Separationrdquo pp 69ndash84 from L Tessman (ed) Feminist Ethics and Social and Political Philosophy Theorizing the Non‐Ideal Springer 2009 With kind permission from Springer Science+Business Media

32 Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death ldquolsquoA Definition of Irreversible Comarsquo Report to Examine the Definition of Brain

xiv acknowledgments

Deathrdquo pp 85ndash8 from Journal of the American Medical Association 205 6 (August 1968) Copyright copy 1968 American Medical Association All rights reserved

33 Ari Joffe ldquoAre Recent Defences of the Brain Death Concept Adequaterdquo pp 47ndash53 from Bioethics 24 2 (February 2010) Reproduced with permission from John Wiley amp Sons

34 Peter Singer ldquoIs the Sanctity of Life Ethic Terminally Illrdquo pp 307ndash43 from Bioethics 9 34 (1995) Reproduced with permission from John Wiley amp Sons

35 Ronald Dworkin ldquoLife Past Reasonrdquo pp 218ndash29 from Lifersquos Dominion An Argument about Abortion Euthanasia and Individual Freedom New York Knopf 1993 Copyright copy 1993 by Ronald Dworkin Used by permission of Alfred A Knopf an imprint of the Knopf Doubleday Publishing Group a division of Random House LLC All rights reserved

36 Rebecca Dresser ldquoDworkin on Dementia Elegant Theory Questionable Policyrdquo pp 32ndash8 from Hastings Center Report 25 6 (NovemberDecember 1995) Reproduced with permission from John Wiley amp Sons

37 Chris Hill ldquoThe Noterdquo pp 9ndash17 from Helga Kuhse (ed) Willing to Listen Wanting to Die Ringwood Australia Penguin Books 1994

38 Daniel Callahan ldquoWhen Self‐Determination Runs Amokrdquo pp 52ndash5 from Hastings Center Report 22 2 (MarchApril 1992) Reproduced with permission from John Wiley amp Sons

39 John Lachs ldquoWhen Abstract Moralizing Runs Amokrdquo pp 10ndash13 from The Journal of Clinical Ethics 5 1 (Spring 1994) Copyright JCE

40 Bregje D Onwuteaka‐Philipsen et al ldquoTrends in End‐Of‐Life Practices Before and After the Enactment of the Euthanasia Law in the Netherlands from 1990 to 2010 A Repeated Cross‐Sectional Surveyrdquo pp 908ndash15 from The Lancet 380 9845 (2012) Reprinted from The Lancet with permission from Elsevier

41 Bernard Lo ldquoEuthanasia in the Netherlands What Lessons for Elsewhererdquo pp 869ndash70 from The Lancet 380 (September 8 2012) Copyright 2012 Reprinted from The Lancet with permisshysion from Elsevier

42 Paul T Menzel ldquoRescuing Lives Canrsquot We Countrdquo pp 22ndash3 from Hastings Center Report 24 1 (1994) Reproduced with permission from John Wiley amp Sons

43 Alvin H Moss and Mark Siegler ldquoShould Alcoholics Compete Equally for Liver Transshyplantationrdquo pp 1295ndash8 from Journal of the American Medical Association 265 10 (1991) Copyright copy 1991 American Medical Association All rights reserved

44 John Harris ldquoThe Value of Liferdquo pp 87ndash102 from The Value of Life London Routledge 1985 Copyright 1985 Routledge Reproduced by permission of Taylor amp Francis Books UK

45 Nick Beckstead and Toby Ord ldquoBubbles under the Wallpaper Healthcare Rationing and Disshycriminationrdquo a paper presented to the confershyence ldquoValuing Livesrdquo New York University March 5 2011 copy Nick Beckstead and Toby Ord reprinted by permission of the authors This paper is published here for the first time but draws on Nick Beckstead and Toby Ord ldquoRationing and Rationality The Cost of Avoiding Discriminationrdquo in N Eyal et al (eds) Inequalities in Health Concepts Measures and Ethics Oxford Oxford University Press 2013 pp 232ndash9 By permission of Oxford University Press

46 Eike‐Henner W Kluge ldquoOrgan Donation and Retrieval Whose Body Is It Anywayrdquo copy 1999 by Eike‐Henner W Kluge

47 Janet Radcliffe‐Richards et al ldquoThe Case for Allowing Kidney Salesrdquo pp 1950ndash2 from The Lancet 351 9120 (June 27 1998) Reprinted with permission from Elsevier

48 Debra Satz ldquoEthical Issues in the Supply and Demand of Human Kidneysrdquo pp 189ndash206 from Why Some Things Should Not Be for Sale The Moral Limits of Markets New York Oxford University Press 2010 ch 9 based on an article from Proceedings of the Aristotelian Society Reprinted by courtesy of the Editor of Proceedings of the Aristotelian Society copy 2010

49 John Harris ldquoThe Survival Lotteryrdquo pp 81ndash7 from Philosophy 50 (1975) copy Royal Institute of Philosophy published by Cambridge University Press Reproduced with permission

Acknowledgments xv

50 Henry K Beecher ldquoEthics and Clinical Researchrdquo pp 1354ndash60 from New England Journal of Medicine 274 24 (June 1966) Copyright copy 1996 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

51 Benjamin Freedman ldquoEquipoise and the Ethics of Clinical Researchrdquo pp 141ndash5 from New England Journal of Medicine 317 3 (July 1987) Copyright copy 1987 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

52 Samuel Hellman ldquoThe Patient and the Public Goodrdquo pp 400ndash2 from Nature Medicine 1 5 (1995) Reprinted by permission from Macmillan Publishers Ltd

53 John Harris ldquoScientific Research Is a Moral Dutyrdquo pp 242ndash8 from Journal of Medical Ethics 31 4 (2005) Reproduced with permission from BMJ Publishing Group

54 Sandra Shapshay and Kenneth D Pimple ldquoParticipation in Research Is an Imperfect Moral Duty A Response to John Harrisrdquo pp 414ndash17 from Journal of Medical Ethics 33 (2007) Reproduced with permission from BMJ Publishing Group

55 Peter Lurie and Sidney M Wolfe ldquoUnethical Trials of Interventions to Reduce Perinatal Transmission of the Human Immunodeficiency Virus in Developing Countriesrdquo pp 853ndash6 from New England Journal of Medicine 337 12 (September 1997) Copyright copy 1997 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

56 Danstan Bageda and Philippa Musoke‐Mudido ldquoWersquore Trying to Help Our Sickest People Not Exploit Themrdquo from The Washington Post September 28 1997 copy 1997 Washington Post Company All rights reserved Used by permisshysion and protected by the Copyright Laws of the United States The printing copying redistribushytion or retransmission of this Content without express written permission is prohibited

57 Leah Belsky and Henry S Richardson ldquoMedical Researchersrsquo Ancillary Clinical Care Respon sibilitiesrdquo pp 1494ndash6 from British

Medical Journal 328 (June 19 2004) Reproduced with permission from BMJ Publishing Group

58 George W Bush ldquoPresident Discusses Stem Cell Researchrdquo Office of the Press Secretary White House August 9 2001

59 Jeff McMahan ldquoKilling Embryos for Stem Cell Researchrdquo pp 170ndash89 from Metaphilosophy 38 23 (2007) Reproduced with permission from John Wiley amp Sons

60 Immanuel Kant ldquoDuties towards Animalsrdquo pp 239ndash41 from Lectures on Ethics trans Louis Infield London Methuen 1930 Copyright 1930 Methuen reproduced by permission of Taylor amp Francis Books UK

61 Jeremy Bentham ldquoA Utilitarian Viewrdquo section XVIII IV from An Introduction to the Principles of Morals and Legislation First published c1820

62 Peter Singer ldquoAll Animals are Equalrdquo pp 103ndash16 from Philosophic Exchange 1 5 (1974) Center for Philosophic Exchange State University of New York Brockford NY 1974

63 R G Frey and Sir William Paton ldquoVivisection Morals and Medicine An Exchangerdquo pp 94ndash7 and 102ndash4 from Journal of Medical Ethics 9 (1983) Reproduced with permission from BMJ Publishing Group

64 Michael J Selgelid ldquoEthics and Infectious Diseaserdquo pp 272ndash89 from Bioethics 19 3 (2005) Reproduced with permission from John Wiley amp Sons

65 Udo Schuumlklenk and Anita Kleinsmidt ldquoRethinking Mandatory HIV Testing during Pregnancy in Areas with High HIV Prevalence Rates Ethical and Policy Issuesrdquo pp 1179ndash83 from American Journal of Public Health 97 7 (2007) Reproduced with permission from American Public Health Association

66 Russell Armstrong ldquoMandatory HIV Testing in Pregnancy Is There Ever a Timerdquo pp 1ndash10 from Developing World Bioethics 8 1 (2008) Reproduced with permission from John Wiley amp Sons

67 Jerome Amir Singh Ross Upshur and Nesri Padayatchi ldquoXDR‐TB in South Africa No Time for Denial or Complacencyrdquo PLoS Med 4 1 (2007) e50 doi101371journalpmed0040050 Copyright copy 2007 Singh et al

xvi acknowledgments

68 Mark Siegler ldquoConfidentiality in Medicine A Decrepit Conceptrdquo pp 1518ndash21 from New England Journal of Medicine 307 24 (December 1982) Copyright copy 1982 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

69 Christian Saumlfken and Andreas Frewer ldquoThe Duty to Warn and Clinical Ethics Legal and Ethical Aspects of Confidentiality and HIVAIDSrdquo pp 313ndash326 from HEC Forum 19 4 (2007) With kind permission from Springer Science+Business Media

70 Immanuel Kant ldquoOn a Supposed Right to Lie from Altruistic Motivesrdquo pp 361ndash3 from Critique of Practical Reason and Other Works on the Theory of Ethics 6th edition trans T K Abbott London 1909 This essay was first published in a Berlin periodical in 1797

71 Joseph Collins ldquoShould Doctors Tell the Truthrdquo pp 320ndash6 from Harperrsquos Monthly Magazine 155 (August 1927) Copyright copy 1927 Harperrsquos Magazine All rights reserved Reproduced from the August issue by special permission

72 Roger Higgs ldquoOn Telling Patients the Truthrdquo pp 186ndash202 and 232ndash3 from Michael Lockwood (ed) Moral Dilemmas in Modern Medicine Oxford Oxford University Press 1985 By permission of Oxford University Press

73 John Stuart Mill ldquoOn Libertyrdquo first published in 1859

74 Justice Benjamin N Cardozo Judgment from Schloendorff v New York Hospital (1914) p 526 from Jay Katz (ed) Experimentation with Human Beings The Authority of the Investigator Subject Professions and State in the Human Experimentation Process New York Russell Sage Foundation 1972 Reproduced with permission of Russell Sage Foundation

75 Tom L Beauchamp ldquoInformed Consent Its History Meaning and Present Challengesrdquo pp 515ndash23 from Cambridge Quarterly of Health Care Ethics 20 4 (2011) copy Royal Institute of Philosophy published by Cambridge University Press Reproduced with permission from Cambridge University Press and T Beauchamp

76 Ruth Macklin ldquoThe DoctorndashPatient Relationshyship in Different Culturesrdquo pp 86ndash107 from

Against Relativism Cultural Diversity and the Search of Ethical Universals in Medicine copy 1999 by Oxford University Press Inc By permission of Oxford University Press USA

77 Carl Elliott ldquoAmputees by Choicerdquo pp 208ndash10 210ndash15 219ndash23 227ndash31 234ndash6 323ndash6 from Better Than Well American Medicine Meets the American Dream New York and London WW Norton 2003 Copyright copy 2003 by Carl Elliott Used by permission of W W Norton amp Company Inc

78 Julian Savulescu ldquoRational Desires and the Limishytation of Life‐Sustaining Treatmentrdquo pp 191ndash 222 from Bioethics 8 3 (1994) Reproduced with permission from John Wiley amp Sons

79 Shlomo Cohen ldquoThe Nocebo Effect of Informed Consentrdquo pp 147ndash54 from Bioethics 28 3 (2014) Reproduced with permission from John Wiley amp Sons

80 Sarah E Dock ldquoThe Relation of the Nurse to the Doctor and the Doctor to the Nurserdquo p 394 (extract) from The American Journal of Nursing 17 5 (1917)

81 Lisa H Newton ldquoIn Defense of the Traditional Nurserdquo pp 348ndash54 from Nursing Outlook 29 6 (1981) Copyright Elsevier 1981

82 Sarah Breier ldquoPatient Autonomy and Medical Paternity Can Nurses Help Doctors to Listen to Patientsrdquo pp 510ndash21 from Nursing Ethics 8 6 (2001) Reproduced with permission from Sage and S Breier

83 Carol Pavlish Anita Ho and Ann‐Marie Rounkle ldquoHealth and Human Rights Advocacy Perspectives from a Rwandan Refugee Camprdquo pp 538ndash49 from Nursing Ethics 19 4 (2012) Copyright copy 2012 by SAGE Publications Reprinted by Permission of SAGE

84 Jonathan D Moreno ldquoNeuroethics An Agenda for Neuroscience and Societyrdquo pp 149ndash53 from Nature Reviews 4 (February 2003)Reprinted by permission from Macmillan Publishers Ltd

85 Sally Adee ldquoHow Electrical Brain Stimulation Can Change the Way We Thinkrdquo The Week March 30 2012

86 Neil Levy ldquoNeuroethics Ethics and the Sciences of the Mindrdquo pp 69ndash74 (extract) from Philosophy

Acknowledgments xvii

Compass 4 10 (2009) pp 69ndash81 Reproduced with permission from John Wiley amp Sons

87 Adam Kolber ldquoFreedom of Memory Todayrdquo pp 145ndash8 from Neuroethics 1 (2008) With kind permission from Springer Science+Business Media

88 Henry Greely and Colleagues ldquoTowards Responsible Use of Cognitive‐Enhancing Drugs

by the Healthyrdquo pp 702ndash5 from Nature 456 (December 11 2008) Reprinted by permission from Macmillan Publishers Ltd

89 Julian Savulescu and Anders Sandberg ldquoEngineering LoverdquoldquoLove Machine Engineering Lifelong Romancerdquo pp 28ndash9 from New Scientist 2864 copy 2012 Reed Business Information ndash UK All rights reserved Distributed by Tribune Content Agency

Bioethics An Anthology Third Edition Edited by Helga Kuhse Udo Schuumlklenk and Peter Singer copy 2016 John Wiley amp Sons Inc Published 2016 by John Wiley amp Sons Inc

Introduction

The term ldquobioethicsrdquo was coined by Van Rensselaer Potter who used it to describe his proposal that we need an ethic that can incorporate our obligations not just to other humans but to the biosphere as a whole1 Although the term is still occasionally used in this sense of an ecological ethic it is now much more commonly used in the narrower sense of the study of ethical issues arising from the biological and medical sciences So understood bioethics has become a specialized although interdisciplinary area of study The essays included in this book give an indication of the range of issues which fall within its scope ndash but it is only an indication There are many other issues that we simply have not had the space to cover

Bioethics can be seen as a branch of ethics or more specifically of applied ethics For this reason some understanding of the nature of ethics is an essential preliminary to any serious study of bioethics The remainder of this introduction will seek to provide that understanding

One question about the nature of ethics is especially relevant to bioethics to what extent is reasoning or argument possible in ethics Many people assume without much thought that ethics is subjective The subjectivist holds that what ethical view we take is a matter of opinion or taste that is not amenable to argument But if ethics were a matter of taste why would we even attempt to argue about it If Helen says ldquoI like my coffee sweetenedrdquo whereas Paul says

ldquoI like my coffee unsweetenedrdquo there is not much point in Helen and Paul arguing about it The two statements do not contradict each other They can both be true But if Helen says ldquoDoctors should never assist their patients to dierdquo whereas Paul says ldquoSometimes doctors should assist their patients to dierdquo then Helen and Paul are disagreeing and there does seem to be a point in their trying to argue about the issue of physician‐assisted suicide

It seems clear that there is some scope for argument in ethics If I say ldquoIt is always wrong to kill a human beingrdquo and ldquoAbortion is not always wrongrdquo then I am committed to denying that abortion kills a human being Otherwise I have contradicted myself and in doing so I have not stated a coherent position at all So consistency at least is a requirement of any defensible ethical position and thus sets a limit to the subjectivity of ethical judgments The requirement of factual accuracy sets another limit In discussing issues in bioethics the facts are often complex But we cannot reach the right ethical decisions unless we are well‐informed about the relevant facts In this respect ethical decisions are unlike decisions of taste We can enjoy a taste without knowing what we are eating but if we assume that it is wrong to resuscitate a terminally ill patient against her wishes then we can-not know whether an instance of resuscitation was morally right or wrong without knowing something about the patientrsquos prognosis and whether the patient

2 introduction

has expressed any wishes about being resuscitated In that sense there is no equivalent in ethics to the immediacy of taste

Ethical relativism sometimes also known as cul-tural relativism is one step away from ethical sub-jectivism but it also severely limits the scope of ethical argument The ethical relativist holds that it is not individual attitudes that determine what is right or wrong but the attitudes of the culture in which one lives Herodotus tells how Darius King of Persia summoned the Greeks from the western shores of his kingdom before him and asked them how much he would have to pay them to eat their fathersrsquo dead bodies They were horrified by the idea and said they would not do it for any amount of money for it was their custom to cremate their dead Then Darius called upon Indians from the eastern frontiers of his kingdom and asked them what would make them willing to burn their fathersrsquo bodies They cried out and asked the King to refrain from mentioning so shocking an act Herodotus comments that each nation thinks its own customs best From here it is only a short step to the view that there can be no objective right or wrong beyond the bounds of onersquos own culture This view found increased support in the nine-teenth century as Western anthropologists came to know many different cultures and were impressed by ethical views very different from those that were standardly taken for granted in European society As a defense against the automatic assumption that Western morality is superior and should be imposed on ldquosavagesrdquo many anthropologists argued that since morality is relative to culture no culture can have any basis for regarding its morality as superior to any other culture

Although the motives with which anthropolo-gists put this view forward were admirable they may not have appreciated the implications of the position they were taking The ethical relativist maintains that a statement like ldquoIt is good to enslave people from another tribe if they are captured in warrdquo means simply ldquoIn my society the custom is to enslave people from another tribe if they are cap-tured in warrdquo Hence if one member of the society were to question whether it really was good to enslave people in these circumstances she could be

answered simply by demonstrating that this was indeed the custom ndash for example by showing that for many generations it had been done after every war in which prisoners were captured Thus there is no way for moral reformers to say that an accepted custom is wrong ndash ldquowrongrdquo just means ldquoin accord-ance with an accepted customrdquo

On the other hand when people from two different cultures disagree about an ethical issue then according to the ethical relativist there can be no resolution of the disagreement Indeed strictly there is no disagree-ment If the apparent dispute were over the issue just mentioned then one person would be saying ldquoIn my country it is the custom to enslave people from another tribe if they are captured in warrdquo and the other person would be saying ldquoIn my country it is not the custom to allow one human being to enslave anotherrdquo This is no more a disagreement than such statements as ldquoIn my country people greet each other by rubbing nosesrdquo and ldquoIn my country people greet each other by shaking handsrdquo If ethical relativism is true then it is impossible to say that one culture is right and the other is wrong Bearing in mind that some cultures have practiced slavery or the burning of widows on the funeral pyre of their husbands this is hard to accept

A more promising alternative to both ethical subjectivism and cultural relativism is universal pre-scriptivism an approach to ethics developed by the Oxford philosopher R M Hare Hare argues that the distinctive property of ethical judgments is that they are universalizable In saying this he means that if I make an ethical judgment I must be prepared to state it in universal terms and apply it to all relevantly similar situations By ldquouniversal termsrdquo Hare means those terms that do not refer to a particular individual Thus a proper name cannot be a universal term If for example I were to say ldquoEveryone should do what is in the interests of Mick Jaggerrdquo I would not be making a universal judgment because I have used a proper name The same would be true if I were to say that everyone must do what is in my interests because the personal pronoun ldquomyrdquo is here used to refer to a particular individual myself

It might seem that ruling out particular terms in this way does not take us very far After all one can always describe oneself in universal terms Perhaps

Introduction 3

I canrsquot say that everyone should do what is in my interests but I could say that everyone must do whatever is in the interests of people who hellip and then give a minutely detailed description of myself including the precise location of all my freckles The effect would be the same as saying that everyone should do what is in my interests because there would be no one except me who matches that description But Hare meets this problem very effectively by saying that to prescribe an ethical judgment universally means being prepared to pre-scribe it for all possible circumstances including hypothetical ones So if I were to say that everyone should do what is in the interests of a person with a particular pattern of freckles I must be prepared to prescribe that in the hypothetical situation in which I do not have this pattern of freckles but someone else does I should do what is in the interests of that person Now of course I may say that I should do that since I am confident that I shall never be in such a situation but this simply means that I am being dishonest I am not genuinely prescribing the principle universally

The effect of saying that an ethical judgment must be universalizable for hypothetical as well as actual circumstances is that whenever I make an ethical judgment I can be challenged to put myself in the position of the parties affected and see if I would still be able to accept that judgment Suppose for example that I own a small factory and the cheapest way for me to get rid of some waste is to pour it into a nearby river I do not take water from this river but I know that some villagers living downstream do and the waste may make them ill The requirement that ethical judgments should be universalizable will make it difficult for me to justify my conduct because if I imagine myself in the hypothetical situation of being one of the villagers rather than the factory‐owner I would not accept that the profits of the factory‐owner should outweigh the risk of adverse effects on my health and that of my children In this way Harersquos approach requires us to take into account the interests and preferences of all others affected by our actions Hence it allows for an element of reasoning in ethical deliberation

Since the rightness or wrongness of our actions will on this view depend on the way in which they

affect others Harersquos universal prescriptivism leads to a form of consequentialism ndash that is the view that the rightness of an action depends on its consequences The best‐known form of consequentialism is the clas-sical utilitarianism developed in the late eighteenth century by Jeremy Bentham and popularized in the nineteenth century by John Stuart Mill They held that an action is right if it leads to a greater surplus of happiness over misery than any possible alternative and wrong if it does not By ldquogreater surplus of happinessrdquo the classical utilitarians had in mind the idea of adding up all the pleasure or happiness that resulted from the action and subtracting from that total all the pain or misery to which the action gave rise Naturally in some circumstances it might be possible only to reduce misery and then the right action should be understood as the one that will result in less misery than any possible alternative

The utilitarian view is striking in many ways It puts forward a single principle that it claims can provide the right answer to all ethical dilemmas if only we can predict what the consequences of our actions will be It takes ethics out of the mysterious realm of duties and rules and bases ethical decisions on something that almost everyone understands and values Moreover utilitarianismrsquos single principle is applied universally without fear or favor Bentham said ldquoEach to count for one and none for more than onerdquo by which he meant that the happiness of a com-mon tramp counted for as much as that of a noble and the happiness of an African was no less important than that of a European

Many contemporary consequentialists agree with Bentham to the extent that they think the rightness or wrongness of an action must depend on its conse-quences but they have abandoned the idea that m aximizing net happiness is the ultimate goal Instead they argue that we should seek to bring about w hatever will satisfy the greatest number of desires or preference This variation which is known as ldquop reference utilitarianismrdquo does not regard anything as good except in so far as it is wanted or desired More intense or strongly held preferences would get more weight than weak preferences

Consequentialism offers one important answer to the question of how we should decide what is right and what is wrong but many ethicists reject it The

4 introduction

denial of this view was dramatically presented by Dostoevsky in The Karamazov Brothers

imagine that you are charged with building the edifice of human destiny the ultimate aim of which is to bring people happiness to give them peace and contentment at last but that in order to achieve this it is essential and unavoidable to torture just one little speck of creation that same little child beating her chest with her little fists and imagine that this edifice has to be erected on her unexpiated tears Would you agree to be the architect under those conditions Tell me honestly2

The passage suggests that some things are always wrong no matter what their consequences This has for most of Western history been the prevailing approach to morality at least at the level of what has been officially taught and approved by the institutions of Church and State The ten commandments of the Hebrew scriptures served as a model for much of the Christian era and the Roman Catholic Church built up an elaborate system of morality based on rules to which no exceptions were allowed

Another example of an ethic of rules is that of Immanuel Kant Kantrsquos ethic is based on his ldquocategori-cal imperativerdquo which he states in several distinct for-mulations One is that we must always act so that we can will the maxim of our action to be a universal law This can be interpreted as a form of Harersquos idea of universalizability which we have already encountered Another is that we must always treat other people as ends never as means While these formulations of the categorical imperative might be applied in various ways in Kantrsquos hands they lead to inviolable rules for example against making promises that we do not intend to keep Kant also thought that it was always wrong to tell a lie In response to a critic who sug-gested that this rule has exceptions Kant said that it would be wrong to lie even if someone had taken refuge in your house and a person seeking to murder him came to your door and asked if you knew where he was Modern Kantians often reject this hard-line approach to rules and claim that Kantrsquos categorical imperative did not require him to hold so strictly to the rule against lying

How would a consequentialist ndash for example a classical utilitarian ndash answer Dostoevskyrsquos challenge If answering honestly ndash and if one really could be certain

that this was a sure way and the only way of bringing lasting happiness to all the people of the world ndash utilitarians would have to say yes they would accept the task of being the architect of the happiness of the world at the cost of the childrsquos unexpiated tears For they would point out that the suffering of that child wholly undeserved as it is will be repeated a million‐fold over the next century for other children just as innocent who are victims of starvation disease and brutality So if this one child must be sacrificed to stop all this suffering then terrible as it is the child must be sacrificed

Fantasy apart there can be no architect of the hap-piness of the world The world is too big and complex a place for that But we may attempt to bring about less suffering and more happiness or satisfaction of preferences for people or sentient beings in specific places and circumstances Alternatively we might fol-low a set of principles or rules ndash which could be of varying degrees of rigidity or flexibility Where would such rules come from Kant tried to deduce them from his categorical imperative which in turn he had reached by insisting that the moral law must be based on reason alone without any content from our wants or desires But the problem with trying to deduce morality from reason alone has always been that it becomes an empty formalism that cannot tell us what to do To make it practical it needs to have some addi-tional content and Kantrsquos own attempts to deduce rules of conduct from his categorical imperative are unconvincing

Others following Aristotle have tried to draw on human nature as a source of moral rules What is good they say is what is natural to human beings They then contend that it is natural and right for us to seek certain goods such as knowledge friendship health love and procreation and unnatural and wrong for us to act contrary to these goods This ldquonatural lawrdquo ethic is open to criticism on several points The word ldquonaturalrdquo can be used both descriptively and evalua-tively and the two senses are often mixed together so that value judgments may be smuggled in under the guise of a description The picture of human nature presented by proponents of natural law ethics usually selects only those characteristics of our nature that the proponent considers desirable The fact that our species especially its male members frequently go to war and

Introduction 5

are also prone to commit individual acts of violence against others is no doubt just as much part of our nature as our desire for knowledge but no natural law theorist therefore views these activities as good More generally natural law theory has its origins in an Aristotelian idea of the cosmos in which everything has a goal or ldquoendrdquo which can be deduced from its nature The ldquoendrdquo of a knife is to cut the assumption is that human beings also have an ldquoendrdquo and we will flourish when we live in accordance with the end for which we are suited But this is a pre‐Darwinian view of nature Since Darwin we know that we do not exist for any purpose but are the result of natural selection operating on random mutations over millions of years Hence there is no reason to believe that living accord-ing to nature will produce a harmonious society let alone the best possible state of affairs for human beings

Another way in which it has been claimed that we can come to know what moral principles or rules we should follow is through our intuition In practice this usually means that we adopt conven-tionally accepted moral principles or rules perhaps with some adjustments in order to avoid inconsist-ency or arbitrariness On this view a moral theory should like a scientific theory try to match the data and the data that a moral theory must match is p rovided by our moral intuitions As in science if a plausible theory matches most but not all of the data then the anomalous data might be rejected on the grounds that it is more likely that there was an error in the procedures for gathering that particular set of data than that the theory as a whole is mis-taken But ultimately the test of a theory is its ability to explain the data The problem with applying this model of scientific justification to ethics is that the ldquodatardquo of our moral intuitions is unreliable not just at one or two specific points but as a whole Here the facts that cultural relativists draw upon are rele-vant (even if they do not establish that cultural rela-tivism is the correct response to it) Since we know that our intuitions are strongly influenced by such things as culture and religion they are ill‐suited to serve as the fixed points against which an ethical theory must be tested Even where there is cross‐cultural agreement there may be some aspects of our intuitions on which all cultures unjustifiably favor our own interests over those of others For

example simply because we are all human beings we may have a systematic bias that leads us to give an unjustifiably low moral status to nonhuman a nimals Or because in virtually all known human societies men have taken a greater leadership role than women the moral intuitions of all societies may not adequately reflect the interests of females

Some philosophers think that it is a mistake to base ethics on principles or rules Instead they focus on what it is to be a good person ndash or in the case of the problems with which this book is concerned perhaps on what it is to be a good nurse or doctor or researcher They seek to describe the virtues that a good person or a good member of the relevant profession should possess Moral education then consists of teaching these virtues and discussing how a virtuous person would act in specific situations The question is how-ever whether we can have a notion of what a virtuous person would do in a specific situation without making a prior decision about what it is right to do After all in any particular moral dilemma different virtues may be applicable and even a particular virtue will not always give unequivocal guidance For instance if a terminally ill patient repeatedly asks a nurse or doctor for assistance in dying what response best exemplifies the virtues of a healthcare professional There seems no answer to this question short of an inquiry into whether it is right or wrong to help a patient in such circumstances to die But in that case we seem bound in the end to come back to discuss-ing such issues as whether it is right to follow moral rules or principles or to do what will have the best consequences

In the late twentieth century some feminists offered new criticisms of conventional thought about ethics They argued that the approaches to ethics taken by the influential philosophers of the past ndash all of whom have been male ndash give too much emphasis to abstract principles and the role of reason and give too little attention to personal relationships and the part played by emotion One outcome of these criticisms has been the development of an ldquoethic of carerdquo which is not so much a single ethical theory as a cluster of ways of looking at ethics which put an attitude of c aring for others at the center and seek to avoid r eliance on abstract ethical principles The ethic of care has seemed especially applicable to the work of those

6 introduction

involved in direct patient care and has recently been taken up by a number of nursing theorists as offering a more suitable alternative to other ideas of ethics Not all feminists however support this development Some worry that the adoption of a ldquocarerdquo approach by nurses may reflect and even reinforce stereotypes of women as more emotional and less rational than men They also fear that it could lead to women continuing to carry a disproportionate burden of caring for others to the exclusion of adequately caring for themselves

In this discussion of ethics we have not mentioned anything about religion This may seem odd in view of the close connection that has often been made between religion and ethics but it reflects our belief that despite this historical connection ethics and reli-gion are fundamentally independent Logically ethics is prior to religion If religious believers wish to say that a deity is good or praise her or his creation or deeds they must have a notion of goodness that is independent of their conception of the deity and what she or he does Otherwise they will be saying that the deity is good and when asked what they mean by ldquogoodrdquo they will have to refer back to the deity saying perhaps that ldquogoodrdquo means ldquoin accord-ance with the wishes of the deityrdquo In that case sen-tences such as ldquoGod is goodrdquo would be a meaningless tautology ldquoGod is goodrdquo could mean no more than ldquoGod is in accordance with Godrsquos wishesrdquo As we have already seen there are ideas of what it is for something to be ldquogoodrdquo that are not rooted in any religious belief While religions typically encourage or instruct their followers to obey a particular ethical code it is obvious that others who do not follow any religion can also think and act ethically

To say that ethics is independent of religion is not to deny that theologians or other religious believers may have a role to play in bioethics Religious traditions often have long histories of dealing with ethical dilem-mas and the accumulation of wisdom and experience that they represent can give us valuable insights into particular problems But these insights should be subject to criticism in the way that any other proposals would be If in the end we accept them it is because we have judged them sound not because they are the utterances of a pope a rabbi a mullah or a holy person

Ethics is also independent of the law in the sense that the rightness or wrongness of an act cannot be

settled by its legality or illegality Whether an act is legal or illegal may often be relevant to whether it is right or wrong because it is arguably wrong to break the law other things being equal Many people have thought that this is especially so in a democracy in which everyone has a say in making the law Another reason why the fact that an act is illegal may be a rea-son against doing it is that the legality of an act may affect the consequences that are likely to flow from it If active voluntary euthanasia is illegal then doctors who practice it risk going to jail which will cause them and their families to suffer and also mean that they will no longer be able to help other patients This can be a powerful reason for not practicing voluntary euthanasia when it is against the law but if there is only a very small chance of the offense becoming known or being proved then the weight of this con-sequentialist reason against breaking the law is reduced accordingly Whether we have an ethical obligation to obey the law and if so how much weight should be given to it is itself an issue for ethical argument

Though ethics is independent of the law in the sense just specified laws are subject to evaluation from an ethical perspective Many debates in bioethics focus on questions about what practices should be allowed ndash for example should we allow research on stem cells taken from human embryos sex selection or cloning ndash and committees set up to advise on the ethical social and legal aspects of these questions often recommend legislation to prohibit the activity in question or to allow it to be practiced under some form of regulation Discussing a question at the level of law and public policy however raises somewhat different considerations than a discussion of personal ethics because the consequences of adopting a public policy generally have much wider ramifications than the consequences of a personal choice That is why some healthcare professionals feel justified in assisting a terminally ill patient to die while at the same time opposing the legalization of physician‐assisted suicide Paradoxical as this position may appear ndash and it is certainly open to criticism ndash it is not straightforwardly inconsistent

Naturally many of the essays we have selected reflect the times in which they were written Since bioethics often comments on developments in fast‐moving

Introduction 7

areas of medicine and the biological sciences the factual content of articles in bioethics can become obsolete quite rapidly In preparing this revised edition we have taken the opportunity to cover some new issues and to include some more recent writings We have for example included new mate-rial on genetic enhancement as well as on the use of embryonic human stem cells This edition of the anthology also includes new sections on ethical issues in public health and in the neurosciences Nevertheless an article that has dated in regard to its facts often makes ethical points that are still valid

or worth considering so we have not excluded older articles for this reason

Other articles are dated in a different way During the past few decades we have become more sensitive about the ways in which our language may exclude women or reflect our prejudices regarding race or sexuality We see no merit in trying to disguise past practices on such matters so we have not excluded otherwise valuable works in bioethics on these grounds If they are jar-ring to the modern reader that may be a salutary reminder of the extent to which we all are subject to the conventions and prejudices of our times

Notes

1 See Van Rensselaer Potter Bioethics Bridge to the Future (Englewood Cliffs NJ Prentice‐Hall 1971)

2 The Karamazov Brothers trans Ignat Avsey (Oxford Oxford University Press 1994) vol I part 2 bk 5 ch 4 First published in 1879

Abortion

Part I

Contents vii

26 Why Killing is Not Always Worse ndash and Sometimes Better ndash Than Letting Die 257Helga Kuhse

27 Moral Fictions and Medical Ethics 261Franklin G Miller Robert D Truog and Dan W Brock

Severely Disabled Newborns 271

28 When Care Cannot Cure Medical Problems in Seriously Ill Babies 273Neil Campbell

29 The Abnormal Child Moral Dilemmas of Doctors and Parents 285R M Hare

30 Right to Life of Handicapped 290Alison Davis

31 Conjoined Twins Embodied Personhood and Surgical Separation 292Christine Overall

Brain Death 305

32 A Definition of Irreversible Coma 307Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death

33 Are Recent Defences of the Brain Death Concept Adequate 312Ari Joffe

34 Is the Sanctity of Life Ethic Terminally Ill 321Peter Singer

Advance Directives 331

35 Life Past Reason 333Ronald Dworkin

36 Dworkin on Dementia Elegant Theory Questionable Policy 341Rebecca Dresser

Voluntary Euthanasia and Medically Assisted Suicide 351

37 The Note 353Chris Hill

38 When Self‐Determination Runs Amok 357Daniel Callahan

39 When Abstract Moralizing Runs Amok 362John Lachs

40 Trends in End‐of‐Life Practices Before and After the Enactment of the Euthanasia Law in the Netherlands from 1990 to 2010 A Repeated Cross‐Sectional Survey 366Bregje D Onwuteaka‐Philipsen Arianne Brinkman‐Stoppelenburg Corine Penning Gwen J F de Jong‐Krul Johannes J M van Delden and Agnes van der Heide

41 Euthanasia in the Netherlands What Lessons for Elsewhere 377Bernard Lo

viii contents

Part V Resource Allocation 381

Introduction 383

42 Rescuing Lives Canrsquot We Count 387Paul T Menzel

43 Should Alcoholics Compete Equally for Liver Transplantation 390Alvin H Moss and Mark Siegler

44 The Value of Life 397John Harris

45 Bubbles under the Wallpaper Healthcare Rationing and Discrimination 406Nick Beckstead and Toby Ord

Part VI Obtaining Organs 413

Introduction 415

46 Organ Donation and Retrieval Whose Body Is It Anyway 417Eike‐Henner W Kluge

47 The Case for Allowing Kidney Sales 421Janet Radcliffe‐Richards A S Daar R D Guttmann R Hoffenberg I Kennedy M Lock R A Sells N Tilney and for the International Forum for Transplant Ethics

48 Ethical Issues in the Supply and Demand of Human Kidneys 425Debra Satz

49 The Survival Lottery 437John Harris

Part VII Experimentation with Human Participants 443

Introduction 445

Human Participants 449

50 Ethics and Clinical Research 451Henry K Beecher

51 Equipoise and the Ethics of Clinical Research 459Benjamin Freedman

52 The Patient and the Public Good 466Samuel Hellman

53 Scientific Research Is a Moral Duty 471John Harris

54 Participation in Biomedical Research Is an Imperfect Moral Duty A Response to John Harris 483Sandra Shapshay and Kenneth D Pimple

Contents ix

55 Unethical Trials of Interventions to Reduce Perinatal Transmission of the Human Immunodeficiency Virus in Developing Countries 489Peter Lurie and Sidney M Wolfe

56 Wersquore Trying to Help Our Sickest People Not Exploit Them 495Danstan Bagenda and Philippa Musoke‐Mudido

57 Medical Researchersrsquo Ancillary Clinical Care Responsibilities 497Leah Belsky and Henry S Richardson

Human Embryos ndash Stem Cells 503

58 President Discusses Stem Cell Research 505George W Bush

59 Killing Embryos for Stem Cell Research 508Jeff McMahan

Part VIII Experimentation with Animals 521

Introduction 523

60 Duties towards Animals 527Immanuel Kant

61 A Utilitarian View 529Jeremy Bentham

62 All Animals Are Equal 530Peter Singer

63 Vivisection Morals and Medicine An Exchange 540R G Frey and Sir William Paton

Part IX Public Health Issues 551

Introduction 553

64 Ethics and Infectious Disease 555Michael J Selgelid

65 Rethinking Mandatory HIV Testing during Pregnancy in Areas with High HIV Prevalence Rates Ethical and Policy Issues 565Udo Schuumlklenk and Anita Kleinsmidt

66 Mandatory HIV Testing in Pregnancy Is There Ever a Time 572Russell Armstrong

67 XDR‐TB in South Africa No Time for Denial or Complacency 582Jerome Amir Singh Ross Upshur and Nesri Padayatchi

x contents

Part X Ethical Issues in the Practice of Healthcare 591

Introduction 593

Confidentiality 597

68 Confidentiality in Medicine A Decrepit Concept 599Mark Siegler

69 The Duty to Warn and Clinical Ethics Legal and Ethical Aspects of Confidentiality and HIVAIDS 603Christian Saumlfken and Andreas Frewer

Truth-Telling 611

70 On a Supposed Right to Lie from Altruistic Motives 613Immanuel Kant

71 Should Doctors Tell the Truth 615Joseph Collins

72 On Telling Patients the Truth 621Roger Higgs

Informed Consent and Patient Autonomy 629

73 On Liberty 631John Stuart Mill

74 From Schloendorff v NewYork Hospital 634Justice Benjamin N Cardozo

75 Informed Consent Its History Meaning and Present Challenges 635Tom L Beauchamp

76 The DoctorndashPatient Relationship in Different Cultures 642Ruth Macklin

77 Amputees by Choice 654Carl Elliott

78 Rational Desires and the Limitation of Life‐Sustaining Treatment 665Julian Savulescu

79 The Nocebo Effect of Informed Consent 683Shlomo Cohen

Part XI Special Issues Facing Nurses 693

Introduction 695

80 The Relation of the Nurse to the Doctor and the Doctor to the Nurse 699Sarah E Dock

81 In Defense of the Traditional Nurse 700Lisa H Newton

Contents xi

82 Patient Autonomy and Medical Paternity Can Nurses Help Doctors to Listen to Patients 708Sarah Breier

83 Health and Human Rights Advocacy Perspectives from a Rwandan Refugee Camp 718Carol Pavlish Anita Ho and Ann‐Marie Rounkle

Part XII Neuroethics 729

Introduction 731

84 Neuroethics An Agenda for Neuroscience and Society 733Jonathan D Moreno

85 How Electrical Brain Stimulation Can Change the Way We Think 741Sally Adee

86 Neuroethics Ethics and the Sciences of the Mind 744Neil Levy

87 Freedom of Memory Today 749Adam Kolber

88 Towards Responsible Use of Cognitive‐Enhancing Drugs by the Healthy 753Henry Greely Barbara Sahakian John Harris Ronald C Kessler Michael Gazzaniga Philip Campbell and Martha J Farah

89 Engineering Love 760Julian Savulescu and Anders Sandberg

Index 762

Acknowledgments

The editor and publisher gratefully acknowledge the permission granted to reproduce the copyright material in this book

1 John Finnis ldquoAbortion and Health Care Ethicsrdquo pp 547ndash57 from Raanan Gillon (ed) Principles of Health Care Ethics Chichester John Wiley 1994 Reproduced with permission from John Wiley amp Sons

2 Michael Tooley ldquoAbortion and Infanticiderdquo pp 37ndash65 from Philosophy and Public Affairs 1 (1972) Reproduced with permission from John Wiley amp Sons

3 Judith Jarvis Thomson ldquoA Defense of Abortionrdquo pp 47ndash66 from Philosophy and Public Affairs 1 1 (1971) Reproduced with permission from John Wiley amp Sons

4 Don Marquis ldquoWhy Abortion Is Immoralrdquo Journal of Philosophy 86 4 (April 1989) 183ndash202

5 Gregory Pence ldquoMultiple Gestation and Damaged Babies Godrsquos Will or Human Choicerdquo This essay draws on ldquoThe McCaughey Septuplets Godrsquos Will or Human Choicerdquo pp 39ndash43 from Gregory Pence Brave New Bioethics Lanham MD Rowman amp Littlefield 2002 copy Gregory Pence 2002 Courtesy of G Pence

6 Dorothy A Greenfeld and Emre Seli ldquoAssisted Reproduction in Same Sex Couplesrdquo pp 289ndash301 from M V Sauer (ed) Principles of Oocyte and Embryo Donation Springer‐Verlag 2013 With kind permisshysion from Springer Science+Business Media

7 Derek Parfit ldquoRights Interests and Possible Peoplerdquo pp 369ndash75 from Samuel Gorovitz et al (eds) Moral

Problems in Medicine Englewood Cliffs NJ Prentice Hall 1976 Courtesy of D Parfit

8 Ruby Catsanos Wendy Rogers and Mianna Lotz ldquoThe Ethics of Uterus Transplantationrdquo pp 65ndash73 from Bioethics 27 2 (2013) Reproduced by permission of John Wiley amp Sons

9 Laura M Purdy ldquoGenetics and Reproductive Risk Can Having Children be Immoralrdquo pp 39ndash49 from Reproducing Persons Issues in Feminist Bioethics Ithaca NY Cornell University Press 1996 Reproduced with permission from Cornell University Press

10 Adrienne Asch ldquoPrenatal Diagnosis and Selective Abortion A Challenge to Practice and Policyrdquo pp 1649ndash57 from American Journal of Public Health 89 11 (1999) Reproduced with permisshysion from American Public Health Association

11 Ruth Chadwick and Mairi Levitt ldquoGenetic Technology A Threat to Deafnessrdquo pp 209ndash15 from Medicine Healthcare and Philosophy 1 (1998) With kind permission from Springer Science+ Business Media

12 The Ethics Committee of the American Society of Reproductive Medicine ldquoSex Selection and Preimplantation Genetic Diagnosisrdquo pp 595ndash8 from Fertility and Sterility 72 4 (October 1999) Reprinted with permission from Elsevier

13 Julian Savulescu and Edgar Dahl ldquoSex Selection and Preimplantation Diagnosis A Response to the Ethics Committee of the American Society of Reproductive Medicinerdquo pp 1879ndash80 from Human Reproduction 15 9 (2000) By permission of Oxford University Press

Acknowledgments xiii

14 John A Robertson Jeffrey P Kahn and John E Wagner ldquoConception to Obtain Hematopoietic Stem Cellsrdquo pp 34ndash40 from Hastings Center Report 32 3 (MayJune 2002) Reproduced with permission from John Wiley amp Sons

15 David King ldquoWhy We Should Not Permit Embryos to Be Selected as Tissue Donorsrdquo pp 13ndash16 from The Bulletin of Medical Ethics 190 (August 2003) Copyright copy RSM Press 2003 Reproduced by permission of SAGE Publications Ltd London Los Angeles New Delhi Singapore and Washington DC

16 Michael Tooley ldquoThe Moral Status of the Cloning of Humansrdquo pp 67ndash101 from James M Humber and Robert I Almeder (eds) Human Cloning Totowa NJ Humana Press 1998 With kind permission from Springer Science+Business Media

17 Jonathan Glover ldquoQuestions about Some Uses of Genetic Engineeringrdquo pp 25ndash33 33ndash6 42ndash3 and 45ndash53 from What Sort of People Should There Be Harmondsworth Penguin Books 1984 Reproshyduced by permission of Penguin Books Ltd

18 David B Resnik ldquoThe Moral Significance of the TherapyndashEnhancement Distinction in Human Geneticsrdquo pp 365ndash77 from Cambridge Quarterly of Healthcare Ethics 9 3 (Summer 2000) copy Cambridge University Press Reproduced with permission

19 Ainsley Newson and Robert Williamson ldquoShould We Undertake Genetic Research on Intelligencerdquo pp 327ndash42 from Bioethics 13 34 (1999) Reproduced with permission from John Wiley amp Sons

20 Nick Bostrom ldquoIn Defense of Posthuman Dignityrdquo pp 202ndash14 from Bioethics 19 3 (2005) Reproduced with permission from John Wiley amp Sons

21 Jonathan Glover ldquoThe Sanctity of Liferdquo pp 39ndash59 from Causing Death and Lives London Pelican 1977 Reproduced by permission of Penguin Books Ltd

22 Sacred Congregation for the Doctrine of the Faith ldquoDeclaration on Euthanasiardquo Vatican City 1980

23 Germain Grisez and Joseph M Boyle Jr ldquoThe Morality of Killing A Traditional Viewrdquo

pp 381ndash419 from Life and Death with Liberty and Justice A Contribution to the Euthanasia Debate Notre Dame IN University of Notre Dame Press 1971

24 James Rachels ldquoActive and Passive Euthanasiardquo pp 78ndash80 from New England Journal of Medicine 292 (1975) Copyright copy 1975 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

25 Winston Nesbitt ldquoIs Killing No Worse Than Letting Dierdquo pp 101ndash5 from Journal of Applied Philosophy 12 1 (1995) Reproduced with permission from John Wiley amp Sons

26 Helga Kuhse ldquoWhy Killing Is Not Always Worse ndash and Sometimes Better ndash Than Letting Dierdquo pp 371ndash4 from Cambridge Quarterly of Healthcare 7 4 (1998) copy Cambridge University Press Reproduced with permission

27 Franklin G Miller Robert D Truog and Dan W Brock ldquoMoral Fictions and Medical Ethicsrdquo pp 453ndash60 from Bioethics 24 9 (2010) Reproduced with permission from John Wiley amp Sons

28 Neil Campbell ldquoWhen Care Cannot Cure Medical Problems in Seriously Ill Babiesrdquo pp 327ndash44 from F K Beller and R F Weir (eds) The Beginning of Human Life Dordrecht Kluwer Academic Publishers 1994 With kind pershymission from Springer Science+Business Media

29 R M Hare ldquoThe Abnormal Child Moral Dilemmas of Doctors and Parentsrdquo Reprinted in Essays on Bioethics Oxford Clarendon Press 1993 pp185ndash91 Courtesy of the Estate of R M Hare

30 Alison Davis ldquoRight to Life of Handicappedrdquo p 181 from Journal of Medical Ethics 9 (1983) Reproduced with permission from BMJ Publishing Group

31 Christine Overall ldquoConjoined Twins Embodied Personhood and Surgical Separationrdquo pp 69ndash84 from L Tessman (ed) Feminist Ethics and Social and Political Philosophy Theorizing the Non‐Ideal Springer 2009 With kind permission from Springer Science+Business Media

32 Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death ldquolsquoA Definition of Irreversible Comarsquo Report to Examine the Definition of Brain

xiv acknowledgments

Deathrdquo pp 85ndash8 from Journal of the American Medical Association 205 6 (August 1968) Copyright copy 1968 American Medical Association All rights reserved

33 Ari Joffe ldquoAre Recent Defences of the Brain Death Concept Adequaterdquo pp 47ndash53 from Bioethics 24 2 (February 2010) Reproduced with permission from John Wiley amp Sons

34 Peter Singer ldquoIs the Sanctity of Life Ethic Terminally Illrdquo pp 307ndash43 from Bioethics 9 34 (1995) Reproduced with permission from John Wiley amp Sons

35 Ronald Dworkin ldquoLife Past Reasonrdquo pp 218ndash29 from Lifersquos Dominion An Argument about Abortion Euthanasia and Individual Freedom New York Knopf 1993 Copyright copy 1993 by Ronald Dworkin Used by permission of Alfred A Knopf an imprint of the Knopf Doubleday Publishing Group a division of Random House LLC All rights reserved

36 Rebecca Dresser ldquoDworkin on Dementia Elegant Theory Questionable Policyrdquo pp 32ndash8 from Hastings Center Report 25 6 (NovemberDecember 1995) Reproduced with permission from John Wiley amp Sons

37 Chris Hill ldquoThe Noterdquo pp 9ndash17 from Helga Kuhse (ed) Willing to Listen Wanting to Die Ringwood Australia Penguin Books 1994

38 Daniel Callahan ldquoWhen Self‐Determination Runs Amokrdquo pp 52ndash5 from Hastings Center Report 22 2 (MarchApril 1992) Reproduced with permission from John Wiley amp Sons

39 John Lachs ldquoWhen Abstract Moralizing Runs Amokrdquo pp 10ndash13 from The Journal of Clinical Ethics 5 1 (Spring 1994) Copyright JCE

40 Bregje D Onwuteaka‐Philipsen et al ldquoTrends in End‐Of‐Life Practices Before and After the Enactment of the Euthanasia Law in the Netherlands from 1990 to 2010 A Repeated Cross‐Sectional Surveyrdquo pp 908ndash15 from The Lancet 380 9845 (2012) Reprinted from The Lancet with permission from Elsevier

41 Bernard Lo ldquoEuthanasia in the Netherlands What Lessons for Elsewhererdquo pp 869ndash70 from The Lancet 380 (September 8 2012) Copyright 2012 Reprinted from The Lancet with permisshysion from Elsevier

42 Paul T Menzel ldquoRescuing Lives Canrsquot We Countrdquo pp 22ndash3 from Hastings Center Report 24 1 (1994) Reproduced with permission from John Wiley amp Sons

43 Alvin H Moss and Mark Siegler ldquoShould Alcoholics Compete Equally for Liver Transshyplantationrdquo pp 1295ndash8 from Journal of the American Medical Association 265 10 (1991) Copyright copy 1991 American Medical Association All rights reserved

44 John Harris ldquoThe Value of Liferdquo pp 87ndash102 from The Value of Life London Routledge 1985 Copyright 1985 Routledge Reproduced by permission of Taylor amp Francis Books UK

45 Nick Beckstead and Toby Ord ldquoBubbles under the Wallpaper Healthcare Rationing and Disshycriminationrdquo a paper presented to the confershyence ldquoValuing Livesrdquo New York University March 5 2011 copy Nick Beckstead and Toby Ord reprinted by permission of the authors This paper is published here for the first time but draws on Nick Beckstead and Toby Ord ldquoRationing and Rationality The Cost of Avoiding Discriminationrdquo in N Eyal et al (eds) Inequalities in Health Concepts Measures and Ethics Oxford Oxford University Press 2013 pp 232ndash9 By permission of Oxford University Press

46 Eike‐Henner W Kluge ldquoOrgan Donation and Retrieval Whose Body Is It Anywayrdquo copy 1999 by Eike‐Henner W Kluge

47 Janet Radcliffe‐Richards et al ldquoThe Case for Allowing Kidney Salesrdquo pp 1950ndash2 from The Lancet 351 9120 (June 27 1998) Reprinted with permission from Elsevier

48 Debra Satz ldquoEthical Issues in the Supply and Demand of Human Kidneysrdquo pp 189ndash206 from Why Some Things Should Not Be for Sale The Moral Limits of Markets New York Oxford University Press 2010 ch 9 based on an article from Proceedings of the Aristotelian Society Reprinted by courtesy of the Editor of Proceedings of the Aristotelian Society copy 2010

49 John Harris ldquoThe Survival Lotteryrdquo pp 81ndash7 from Philosophy 50 (1975) copy Royal Institute of Philosophy published by Cambridge University Press Reproduced with permission

Acknowledgments xv

50 Henry K Beecher ldquoEthics and Clinical Researchrdquo pp 1354ndash60 from New England Journal of Medicine 274 24 (June 1966) Copyright copy 1996 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

51 Benjamin Freedman ldquoEquipoise and the Ethics of Clinical Researchrdquo pp 141ndash5 from New England Journal of Medicine 317 3 (July 1987) Copyright copy 1987 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

52 Samuel Hellman ldquoThe Patient and the Public Goodrdquo pp 400ndash2 from Nature Medicine 1 5 (1995) Reprinted by permission from Macmillan Publishers Ltd

53 John Harris ldquoScientific Research Is a Moral Dutyrdquo pp 242ndash8 from Journal of Medical Ethics 31 4 (2005) Reproduced with permission from BMJ Publishing Group

54 Sandra Shapshay and Kenneth D Pimple ldquoParticipation in Research Is an Imperfect Moral Duty A Response to John Harrisrdquo pp 414ndash17 from Journal of Medical Ethics 33 (2007) Reproduced with permission from BMJ Publishing Group

55 Peter Lurie and Sidney M Wolfe ldquoUnethical Trials of Interventions to Reduce Perinatal Transmission of the Human Immunodeficiency Virus in Developing Countriesrdquo pp 853ndash6 from New England Journal of Medicine 337 12 (September 1997) Copyright copy 1997 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

56 Danstan Bageda and Philippa Musoke‐Mudido ldquoWersquore Trying to Help Our Sickest People Not Exploit Themrdquo from The Washington Post September 28 1997 copy 1997 Washington Post Company All rights reserved Used by permisshysion and protected by the Copyright Laws of the United States The printing copying redistribushytion or retransmission of this Content without express written permission is prohibited

57 Leah Belsky and Henry S Richardson ldquoMedical Researchersrsquo Ancillary Clinical Care Respon sibilitiesrdquo pp 1494ndash6 from British

Medical Journal 328 (June 19 2004) Reproduced with permission from BMJ Publishing Group

58 George W Bush ldquoPresident Discusses Stem Cell Researchrdquo Office of the Press Secretary White House August 9 2001

59 Jeff McMahan ldquoKilling Embryos for Stem Cell Researchrdquo pp 170ndash89 from Metaphilosophy 38 23 (2007) Reproduced with permission from John Wiley amp Sons

60 Immanuel Kant ldquoDuties towards Animalsrdquo pp 239ndash41 from Lectures on Ethics trans Louis Infield London Methuen 1930 Copyright 1930 Methuen reproduced by permission of Taylor amp Francis Books UK

61 Jeremy Bentham ldquoA Utilitarian Viewrdquo section XVIII IV from An Introduction to the Principles of Morals and Legislation First published c1820

62 Peter Singer ldquoAll Animals are Equalrdquo pp 103ndash16 from Philosophic Exchange 1 5 (1974) Center for Philosophic Exchange State University of New York Brockford NY 1974

63 R G Frey and Sir William Paton ldquoVivisection Morals and Medicine An Exchangerdquo pp 94ndash7 and 102ndash4 from Journal of Medical Ethics 9 (1983) Reproduced with permission from BMJ Publishing Group

64 Michael J Selgelid ldquoEthics and Infectious Diseaserdquo pp 272ndash89 from Bioethics 19 3 (2005) Reproduced with permission from John Wiley amp Sons

65 Udo Schuumlklenk and Anita Kleinsmidt ldquoRethinking Mandatory HIV Testing during Pregnancy in Areas with High HIV Prevalence Rates Ethical and Policy Issuesrdquo pp 1179ndash83 from American Journal of Public Health 97 7 (2007) Reproduced with permission from American Public Health Association

66 Russell Armstrong ldquoMandatory HIV Testing in Pregnancy Is There Ever a Timerdquo pp 1ndash10 from Developing World Bioethics 8 1 (2008) Reproduced with permission from John Wiley amp Sons

67 Jerome Amir Singh Ross Upshur and Nesri Padayatchi ldquoXDR‐TB in South Africa No Time for Denial or Complacencyrdquo PLoS Med 4 1 (2007) e50 doi101371journalpmed0040050 Copyright copy 2007 Singh et al

xvi acknowledgments

68 Mark Siegler ldquoConfidentiality in Medicine A Decrepit Conceptrdquo pp 1518ndash21 from New England Journal of Medicine 307 24 (December 1982) Copyright copy 1982 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

69 Christian Saumlfken and Andreas Frewer ldquoThe Duty to Warn and Clinical Ethics Legal and Ethical Aspects of Confidentiality and HIVAIDSrdquo pp 313ndash326 from HEC Forum 19 4 (2007) With kind permission from Springer Science+Business Media

70 Immanuel Kant ldquoOn a Supposed Right to Lie from Altruistic Motivesrdquo pp 361ndash3 from Critique of Practical Reason and Other Works on the Theory of Ethics 6th edition trans T K Abbott London 1909 This essay was first published in a Berlin periodical in 1797

71 Joseph Collins ldquoShould Doctors Tell the Truthrdquo pp 320ndash6 from Harperrsquos Monthly Magazine 155 (August 1927) Copyright copy 1927 Harperrsquos Magazine All rights reserved Reproduced from the August issue by special permission

72 Roger Higgs ldquoOn Telling Patients the Truthrdquo pp 186ndash202 and 232ndash3 from Michael Lockwood (ed) Moral Dilemmas in Modern Medicine Oxford Oxford University Press 1985 By permission of Oxford University Press

73 John Stuart Mill ldquoOn Libertyrdquo first published in 1859

74 Justice Benjamin N Cardozo Judgment from Schloendorff v New York Hospital (1914) p 526 from Jay Katz (ed) Experimentation with Human Beings The Authority of the Investigator Subject Professions and State in the Human Experimentation Process New York Russell Sage Foundation 1972 Reproduced with permission of Russell Sage Foundation

75 Tom L Beauchamp ldquoInformed Consent Its History Meaning and Present Challengesrdquo pp 515ndash23 from Cambridge Quarterly of Health Care Ethics 20 4 (2011) copy Royal Institute of Philosophy published by Cambridge University Press Reproduced with permission from Cambridge University Press and T Beauchamp

76 Ruth Macklin ldquoThe DoctorndashPatient Relationshyship in Different Culturesrdquo pp 86ndash107 from

Against Relativism Cultural Diversity and the Search of Ethical Universals in Medicine copy 1999 by Oxford University Press Inc By permission of Oxford University Press USA

77 Carl Elliott ldquoAmputees by Choicerdquo pp 208ndash10 210ndash15 219ndash23 227ndash31 234ndash6 323ndash6 from Better Than Well American Medicine Meets the American Dream New York and London WW Norton 2003 Copyright copy 2003 by Carl Elliott Used by permission of W W Norton amp Company Inc

78 Julian Savulescu ldquoRational Desires and the Limishytation of Life‐Sustaining Treatmentrdquo pp 191ndash 222 from Bioethics 8 3 (1994) Reproduced with permission from John Wiley amp Sons

79 Shlomo Cohen ldquoThe Nocebo Effect of Informed Consentrdquo pp 147ndash54 from Bioethics 28 3 (2014) Reproduced with permission from John Wiley amp Sons

80 Sarah E Dock ldquoThe Relation of the Nurse to the Doctor and the Doctor to the Nurserdquo p 394 (extract) from The American Journal of Nursing 17 5 (1917)

81 Lisa H Newton ldquoIn Defense of the Traditional Nurserdquo pp 348ndash54 from Nursing Outlook 29 6 (1981) Copyright Elsevier 1981

82 Sarah Breier ldquoPatient Autonomy and Medical Paternity Can Nurses Help Doctors to Listen to Patientsrdquo pp 510ndash21 from Nursing Ethics 8 6 (2001) Reproduced with permission from Sage and S Breier

83 Carol Pavlish Anita Ho and Ann‐Marie Rounkle ldquoHealth and Human Rights Advocacy Perspectives from a Rwandan Refugee Camprdquo pp 538ndash49 from Nursing Ethics 19 4 (2012) Copyright copy 2012 by SAGE Publications Reprinted by Permission of SAGE

84 Jonathan D Moreno ldquoNeuroethics An Agenda for Neuroscience and Societyrdquo pp 149ndash53 from Nature Reviews 4 (February 2003)Reprinted by permission from Macmillan Publishers Ltd

85 Sally Adee ldquoHow Electrical Brain Stimulation Can Change the Way We Thinkrdquo The Week March 30 2012

86 Neil Levy ldquoNeuroethics Ethics and the Sciences of the Mindrdquo pp 69ndash74 (extract) from Philosophy

Acknowledgments xvii

Compass 4 10 (2009) pp 69ndash81 Reproduced with permission from John Wiley amp Sons

87 Adam Kolber ldquoFreedom of Memory Todayrdquo pp 145ndash8 from Neuroethics 1 (2008) With kind permission from Springer Science+Business Media

88 Henry Greely and Colleagues ldquoTowards Responsible Use of Cognitive‐Enhancing Drugs

by the Healthyrdquo pp 702ndash5 from Nature 456 (December 11 2008) Reprinted by permission from Macmillan Publishers Ltd

89 Julian Savulescu and Anders Sandberg ldquoEngineering LoverdquoldquoLove Machine Engineering Lifelong Romancerdquo pp 28ndash9 from New Scientist 2864 copy 2012 Reed Business Information ndash UK All rights reserved Distributed by Tribune Content Agency

Bioethics An Anthology Third Edition Edited by Helga Kuhse Udo Schuumlklenk and Peter Singer copy 2016 John Wiley amp Sons Inc Published 2016 by John Wiley amp Sons Inc

Introduction

The term ldquobioethicsrdquo was coined by Van Rensselaer Potter who used it to describe his proposal that we need an ethic that can incorporate our obligations not just to other humans but to the biosphere as a whole1 Although the term is still occasionally used in this sense of an ecological ethic it is now much more commonly used in the narrower sense of the study of ethical issues arising from the biological and medical sciences So understood bioethics has become a specialized although interdisciplinary area of study The essays included in this book give an indication of the range of issues which fall within its scope ndash but it is only an indication There are many other issues that we simply have not had the space to cover

Bioethics can be seen as a branch of ethics or more specifically of applied ethics For this reason some understanding of the nature of ethics is an essential preliminary to any serious study of bioethics The remainder of this introduction will seek to provide that understanding

One question about the nature of ethics is especially relevant to bioethics to what extent is reasoning or argument possible in ethics Many people assume without much thought that ethics is subjective The subjectivist holds that what ethical view we take is a matter of opinion or taste that is not amenable to argument But if ethics were a matter of taste why would we even attempt to argue about it If Helen says ldquoI like my coffee sweetenedrdquo whereas Paul says

ldquoI like my coffee unsweetenedrdquo there is not much point in Helen and Paul arguing about it The two statements do not contradict each other They can both be true But if Helen says ldquoDoctors should never assist their patients to dierdquo whereas Paul says ldquoSometimes doctors should assist their patients to dierdquo then Helen and Paul are disagreeing and there does seem to be a point in their trying to argue about the issue of physician‐assisted suicide

It seems clear that there is some scope for argument in ethics If I say ldquoIt is always wrong to kill a human beingrdquo and ldquoAbortion is not always wrongrdquo then I am committed to denying that abortion kills a human being Otherwise I have contradicted myself and in doing so I have not stated a coherent position at all So consistency at least is a requirement of any defensible ethical position and thus sets a limit to the subjectivity of ethical judgments The requirement of factual accuracy sets another limit In discussing issues in bioethics the facts are often complex But we cannot reach the right ethical decisions unless we are well‐informed about the relevant facts In this respect ethical decisions are unlike decisions of taste We can enjoy a taste without knowing what we are eating but if we assume that it is wrong to resuscitate a terminally ill patient against her wishes then we can-not know whether an instance of resuscitation was morally right or wrong without knowing something about the patientrsquos prognosis and whether the patient

2 introduction

has expressed any wishes about being resuscitated In that sense there is no equivalent in ethics to the immediacy of taste

Ethical relativism sometimes also known as cul-tural relativism is one step away from ethical sub-jectivism but it also severely limits the scope of ethical argument The ethical relativist holds that it is not individual attitudes that determine what is right or wrong but the attitudes of the culture in which one lives Herodotus tells how Darius King of Persia summoned the Greeks from the western shores of his kingdom before him and asked them how much he would have to pay them to eat their fathersrsquo dead bodies They were horrified by the idea and said they would not do it for any amount of money for it was their custom to cremate their dead Then Darius called upon Indians from the eastern frontiers of his kingdom and asked them what would make them willing to burn their fathersrsquo bodies They cried out and asked the King to refrain from mentioning so shocking an act Herodotus comments that each nation thinks its own customs best From here it is only a short step to the view that there can be no objective right or wrong beyond the bounds of onersquos own culture This view found increased support in the nine-teenth century as Western anthropologists came to know many different cultures and were impressed by ethical views very different from those that were standardly taken for granted in European society As a defense against the automatic assumption that Western morality is superior and should be imposed on ldquosavagesrdquo many anthropologists argued that since morality is relative to culture no culture can have any basis for regarding its morality as superior to any other culture

Although the motives with which anthropolo-gists put this view forward were admirable they may not have appreciated the implications of the position they were taking The ethical relativist maintains that a statement like ldquoIt is good to enslave people from another tribe if they are captured in warrdquo means simply ldquoIn my society the custom is to enslave people from another tribe if they are cap-tured in warrdquo Hence if one member of the society were to question whether it really was good to enslave people in these circumstances she could be

answered simply by demonstrating that this was indeed the custom ndash for example by showing that for many generations it had been done after every war in which prisoners were captured Thus there is no way for moral reformers to say that an accepted custom is wrong ndash ldquowrongrdquo just means ldquoin accord-ance with an accepted customrdquo

On the other hand when people from two different cultures disagree about an ethical issue then according to the ethical relativist there can be no resolution of the disagreement Indeed strictly there is no disagree-ment If the apparent dispute were over the issue just mentioned then one person would be saying ldquoIn my country it is the custom to enslave people from another tribe if they are captured in warrdquo and the other person would be saying ldquoIn my country it is not the custom to allow one human being to enslave anotherrdquo This is no more a disagreement than such statements as ldquoIn my country people greet each other by rubbing nosesrdquo and ldquoIn my country people greet each other by shaking handsrdquo If ethical relativism is true then it is impossible to say that one culture is right and the other is wrong Bearing in mind that some cultures have practiced slavery or the burning of widows on the funeral pyre of their husbands this is hard to accept

A more promising alternative to both ethical subjectivism and cultural relativism is universal pre-scriptivism an approach to ethics developed by the Oxford philosopher R M Hare Hare argues that the distinctive property of ethical judgments is that they are universalizable In saying this he means that if I make an ethical judgment I must be prepared to state it in universal terms and apply it to all relevantly similar situations By ldquouniversal termsrdquo Hare means those terms that do not refer to a particular individual Thus a proper name cannot be a universal term If for example I were to say ldquoEveryone should do what is in the interests of Mick Jaggerrdquo I would not be making a universal judgment because I have used a proper name The same would be true if I were to say that everyone must do what is in my interests because the personal pronoun ldquomyrdquo is here used to refer to a particular individual myself

It might seem that ruling out particular terms in this way does not take us very far After all one can always describe oneself in universal terms Perhaps

Introduction 3

I canrsquot say that everyone should do what is in my interests but I could say that everyone must do whatever is in the interests of people who hellip and then give a minutely detailed description of myself including the precise location of all my freckles The effect would be the same as saying that everyone should do what is in my interests because there would be no one except me who matches that description But Hare meets this problem very effectively by saying that to prescribe an ethical judgment universally means being prepared to pre-scribe it for all possible circumstances including hypothetical ones So if I were to say that everyone should do what is in the interests of a person with a particular pattern of freckles I must be prepared to prescribe that in the hypothetical situation in which I do not have this pattern of freckles but someone else does I should do what is in the interests of that person Now of course I may say that I should do that since I am confident that I shall never be in such a situation but this simply means that I am being dishonest I am not genuinely prescribing the principle universally

The effect of saying that an ethical judgment must be universalizable for hypothetical as well as actual circumstances is that whenever I make an ethical judgment I can be challenged to put myself in the position of the parties affected and see if I would still be able to accept that judgment Suppose for example that I own a small factory and the cheapest way for me to get rid of some waste is to pour it into a nearby river I do not take water from this river but I know that some villagers living downstream do and the waste may make them ill The requirement that ethical judgments should be universalizable will make it difficult for me to justify my conduct because if I imagine myself in the hypothetical situation of being one of the villagers rather than the factory‐owner I would not accept that the profits of the factory‐owner should outweigh the risk of adverse effects on my health and that of my children In this way Harersquos approach requires us to take into account the interests and preferences of all others affected by our actions Hence it allows for an element of reasoning in ethical deliberation

Since the rightness or wrongness of our actions will on this view depend on the way in which they

affect others Harersquos universal prescriptivism leads to a form of consequentialism ndash that is the view that the rightness of an action depends on its consequences The best‐known form of consequentialism is the clas-sical utilitarianism developed in the late eighteenth century by Jeremy Bentham and popularized in the nineteenth century by John Stuart Mill They held that an action is right if it leads to a greater surplus of happiness over misery than any possible alternative and wrong if it does not By ldquogreater surplus of happinessrdquo the classical utilitarians had in mind the idea of adding up all the pleasure or happiness that resulted from the action and subtracting from that total all the pain or misery to which the action gave rise Naturally in some circumstances it might be possible only to reduce misery and then the right action should be understood as the one that will result in less misery than any possible alternative

The utilitarian view is striking in many ways It puts forward a single principle that it claims can provide the right answer to all ethical dilemmas if only we can predict what the consequences of our actions will be It takes ethics out of the mysterious realm of duties and rules and bases ethical decisions on something that almost everyone understands and values Moreover utilitarianismrsquos single principle is applied universally without fear or favor Bentham said ldquoEach to count for one and none for more than onerdquo by which he meant that the happiness of a com-mon tramp counted for as much as that of a noble and the happiness of an African was no less important than that of a European

Many contemporary consequentialists agree with Bentham to the extent that they think the rightness or wrongness of an action must depend on its conse-quences but they have abandoned the idea that m aximizing net happiness is the ultimate goal Instead they argue that we should seek to bring about w hatever will satisfy the greatest number of desires or preference This variation which is known as ldquop reference utilitarianismrdquo does not regard anything as good except in so far as it is wanted or desired More intense or strongly held preferences would get more weight than weak preferences

Consequentialism offers one important answer to the question of how we should decide what is right and what is wrong but many ethicists reject it The

4 introduction

denial of this view was dramatically presented by Dostoevsky in The Karamazov Brothers

imagine that you are charged with building the edifice of human destiny the ultimate aim of which is to bring people happiness to give them peace and contentment at last but that in order to achieve this it is essential and unavoidable to torture just one little speck of creation that same little child beating her chest with her little fists and imagine that this edifice has to be erected on her unexpiated tears Would you agree to be the architect under those conditions Tell me honestly2

The passage suggests that some things are always wrong no matter what their consequences This has for most of Western history been the prevailing approach to morality at least at the level of what has been officially taught and approved by the institutions of Church and State The ten commandments of the Hebrew scriptures served as a model for much of the Christian era and the Roman Catholic Church built up an elaborate system of morality based on rules to which no exceptions were allowed

Another example of an ethic of rules is that of Immanuel Kant Kantrsquos ethic is based on his ldquocategori-cal imperativerdquo which he states in several distinct for-mulations One is that we must always act so that we can will the maxim of our action to be a universal law This can be interpreted as a form of Harersquos idea of universalizability which we have already encountered Another is that we must always treat other people as ends never as means While these formulations of the categorical imperative might be applied in various ways in Kantrsquos hands they lead to inviolable rules for example against making promises that we do not intend to keep Kant also thought that it was always wrong to tell a lie In response to a critic who sug-gested that this rule has exceptions Kant said that it would be wrong to lie even if someone had taken refuge in your house and a person seeking to murder him came to your door and asked if you knew where he was Modern Kantians often reject this hard-line approach to rules and claim that Kantrsquos categorical imperative did not require him to hold so strictly to the rule against lying

How would a consequentialist ndash for example a classical utilitarian ndash answer Dostoevskyrsquos challenge If answering honestly ndash and if one really could be certain

that this was a sure way and the only way of bringing lasting happiness to all the people of the world ndash utilitarians would have to say yes they would accept the task of being the architect of the happiness of the world at the cost of the childrsquos unexpiated tears For they would point out that the suffering of that child wholly undeserved as it is will be repeated a million‐fold over the next century for other children just as innocent who are victims of starvation disease and brutality So if this one child must be sacrificed to stop all this suffering then terrible as it is the child must be sacrificed

Fantasy apart there can be no architect of the hap-piness of the world The world is too big and complex a place for that But we may attempt to bring about less suffering and more happiness or satisfaction of preferences for people or sentient beings in specific places and circumstances Alternatively we might fol-low a set of principles or rules ndash which could be of varying degrees of rigidity or flexibility Where would such rules come from Kant tried to deduce them from his categorical imperative which in turn he had reached by insisting that the moral law must be based on reason alone without any content from our wants or desires But the problem with trying to deduce morality from reason alone has always been that it becomes an empty formalism that cannot tell us what to do To make it practical it needs to have some addi-tional content and Kantrsquos own attempts to deduce rules of conduct from his categorical imperative are unconvincing

Others following Aristotle have tried to draw on human nature as a source of moral rules What is good they say is what is natural to human beings They then contend that it is natural and right for us to seek certain goods such as knowledge friendship health love and procreation and unnatural and wrong for us to act contrary to these goods This ldquonatural lawrdquo ethic is open to criticism on several points The word ldquonaturalrdquo can be used both descriptively and evalua-tively and the two senses are often mixed together so that value judgments may be smuggled in under the guise of a description The picture of human nature presented by proponents of natural law ethics usually selects only those characteristics of our nature that the proponent considers desirable The fact that our species especially its male members frequently go to war and

Introduction 5

are also prone to commit individual acts of violence against others is no doubt just as much part of our nature as our desire for knowledge but no natural law theorist therefore views these activities as good More generally natural law theory has its origins in an Aristotelian idea of the cosmos in which everything has a goal or ldquoendrdquo which can be deduced from its nature The ldquoendrdquo of a knife is to cut the assumption is that human beings also have an ldquoendrdquo and we will flourish when we live in accordance with the end for which we are suited But this is a pre‐Darwinian view of nature Since Darwin we know that we do not exist for any purpose but are the result of natural selection operating on random mutations over millions of years Hence there is no reason to believe that living accord-ing to nature will produce a harmonious society let alone the best possible state of affairs for human beings

Another way in which it has been claimed that we can come to know what moral principles or rules we should follow is through our intuition In practice this usually means that we adopt conven-tionally accepted moral principles or rules perhaps with some adjustments in order to avoid inconsist-ency or arbitrariness On this view a moral theory should like a scientific theory try to match the data and the data that a moral theory must match is p rovided by our moral intuitions As in science if a plausible theory matches most but not all of the data then the anomalous data might be rejected on the grounds that it is more likely that there was an error in the procedures for gathering that particular set of data than that the theory as a whole is mis-taken But ultimately the test of a theory is its ability to explain the data The problem with applying this model of scientific justification to ethics is that the ldquodatardquo of our moral intuitions is unreliable not just at one or two specific points but as a whole Here the facts that cultural relativists draw upon are rele-vant (even if they do not establish that cultural rela-tivism is the correct response to it) Since we know that our intuitions are strongly influenced by such things as culture and religion they are ill‐suited to serve as the fixed points against which an ethical theory must be tested Even where there is cross‐cultural agreement there may be some aspects of our intuitions on which all cultures unjustifiably favor our own interests over those of others For

example simply because we are all human beings we may have a systematic bias that leads us to give an unjustifiably low moral status to nonhuman a nimals Or because in virtually all known human societies men have taken a greater leadership role than women the moral intuitions of all societies may not adequately reflect the interests of females

Some philosophers think that it is a mistake to base ethics on principles or rules Instead they focus on what it is to be a good person ndash or in the case of the problems with which this book is concerned perhaps on what it is to be a good nurse or doctor or researcher They seek to describe the virtues that a good person or a good member of the relevant profession should possess Moral education then consists of teaching these virtues and discussing how a virtuous person would act in specific situations The question is how-ever whether we can have a notion of what a virtuous person would do in a specific situation without making a prior decision about what it is right to do After all in any particular moral dilemma different virtues may be applicable and even a particular virtue will not always give unequivocal guidance For instance if a terminally ill patient repeatedly asks a nurse or doctor for assistance in dying what response best exemplifies the virtues of a healthcare professional There seems no answer to this question short of an inquiry into whether it is right or wrong to help a patient in such circumstances to die But in that case we seem bound in the end to come back to discuss-ing such issues as whether it is right to follow moral rules or principles or to do what will have the best consequences

In the late twentieth century some feminists offered new criticisms of conventional thought about ethics They argued that the approaches to ethics taken by the influential philosophers of the past ndash all of whom have been male ndash give too much emphasis to abstract principles and the role of reason and give too little attention to personal relationships and the part played by emotion One outcome of these criticisms has been the development of an ldquoethic of carerdquo which is not so much a single ethical theory as a cluster of ways of looking at ethics which put an attitude of c aring for others at the center and seek to avoid r eliance on abstract ethical principles The ethic of care has seemed especially applicable to the work of those

6 introduction

involved in direct patient care and has recently been taken up by a number of nursing theorists as offering a more suitable alternative to other ideas of ethics Not all feminists however support this development Some worry that the adoption of a ldquocarerdquo approach by nurses may reflect and even reinforce stereotypes of women as more emotional and less rational than men They also fear that it could lead to women continuing to carry a disproportionate burden of caring for others to the exclusion of adequately caring for themselves

In this discussion of ethics we have not mentioned anything about religion This may seem odd in view of the close connection that has often been made between religion and ethics but it reflects our belief that despite this historical connection ethics and reli-gion are fundamentally independent Logically ethics is prior to religion If religious believers wish to say that a deity is good or praise her or his creation or deeds they must have a notion of goodness that is independent of their conception of the deity and what she or he does Otherwise they will be saying that the deity is good and when asked what they mean by ldquogoodrdquo they will have to refer back to the deity saying perhaps that ldquogoodrdquo means ldquoin accord-ance with the wishes of the deityrdquo In that case sen-tences such as ldquoGod is goodrdquo would be a meaningless tautology ldquoGod is goodrdquo could mean no more than ldquoGod is in accordance with Godrsquos wishesrdquo As we have already seen there are ideas of what it is for something to be ldquogoodrdquo that are not rooted in any religious belief While religions typically encourage or instruct their followers to obey a particular ethical code it is obvious that others who do not follow any religion can also think and act ethically

To say that ethics is independent of religion is not to deny that theologians or other religious believers may have a role to play in bioethics Religious traditions often have long histories of dealing with ethical dilem-mas and the accumulation of wisdom and experience that they represent can give us valuable insights into particular problems But these insights should be subject to criticism in the way that any other proposals would be If in the end we accept them it is because we have judged them sound not because they are the utterances of a pope a rabbi a mullah or a holy person

Ethics is also independent of the law in the sense that the rightness or wrongness of an act cannot be

settled by its legality or illegality Whether an act is legal or illegal may often be relevant to whether it is right or wrong because it is arguably wrong to break the law other things being equal Many people have thought that this is especially so in a democracy in which everyone has a say in making the law Another reason why the fact that an act is illegal may be a rea-son against doing it is that the legality of an act may affect the consequences that are likely to flow from it If active voluntary euthanasia is illegal then doctors who practice it risk going to jail which will cause them and their families to suffer and also mean that they will no longer be able to help other patients This can be a powerful reason for not practicing voluntary euthanasia when it is against the law but if there is only a very small chance of the offense becoming known or being proved then the weight of this con-sequentialist reason against breaking the law is reduced accordingly Whether we have an ethical obligation to obey the law and if so how much weight should be given to it is itself an issue for ethical argument

Though ethics is independent of the law in the sense just specified laws are subject to evaluation from an ethical perspective Many debates in bioethics focus on questions about what practices should be allowed ndash for example should we allow research on stem cells taken from human embryos sex selection or cloning ndash and committees set up to advise on the ethical social and legal aspects of these questions often recommend legislation to prohibit the activity in question or to allow it to be practiced under some form of regulation Discussing a question at the level of law and public policy however raises somewhat different considerations than a discussion of personal ethics because the consequences of adopting a public policy generally have much wider ramifications than the consequences of a personal choice That is why some healthcare professionals feel justified in assisting a terminally ill patient to die while at the same time opposing the legalization of physician‐assisted suicide Paradoxical as this position may appear ndash and it is certainly open to criticism ndash it is not straightforwardly inconsistent

Naturally many of the essays we have selected reflect the times in which they were written Since bioethics often comments on developments in fast‐moving

Introduction 7

areas of medicine and the biological sciences the factual content of articles in bioethics can become obsolete quite rapidly In preparing this revised edition we have taken the opportunity to cover some new issues and to include some more recent writings We have for example included new mate-rial on genetic enhancement as well as on the use of embryonic human stem cells This edition of the anthology also includes new sections on ethical issues in public health and in the neurosciences Nevertheless an article that has dated in regard to its facts often makes ethical points that are still valid

or worth considering so we have not excluded older articles for this reason

Other articles are dated in a different way During the past few decades we have become more sensitive about the ways in which our language may exclude women or reflect our prejudices regarding race or sexuality We see no merit in trying to disguise past practices on such matters so we have not excluded otherwise valuable works in bioethics on these grounds If they are jar-ring to the modern reader that may be a salutary reminder of the extent to which we all are subject to the conventions and prejudices of our times

Notes

1 See Van Rensselaer Potter Bioethics Bridge to the Future (Englewood Cliffs NJ Prentice‐Hall 1971)

2 The Karamazov Brothers trans Ignat Avsey (Oxford Oxford University Press 1994) vol I part 2 bk 5 ch 4 First published in 1879

Abortion

Part I

viii contents

Part V Resource Allocation 381

Introduction 383

42 Rescuing Lives Canrsquot We Count 387Paul T Menzel

43 Should Alcoholics Compete Equally for Liver Transplantation 390Alvin H Moss and Mark Siegler

44 The Value of Life 397John Harris

45 Bubbles under the Wallpaper Healthcare Rationing and Discrimination 406Nick Beckstead and Toby Ord

Part VI Obtaining Organs 413

Introduction 415

46 Organ Donation and Retrieval Whose Body Is It Anyway 417Eike‐Henner W Kluge

47 The Case for Allowing Kidney Sales 421Janet Radcliffe‐Richards A S Daar R D Guttmann R Hoffenberg I Kennedy M Lock R A Sells N Tilney and for the International Forum for Transplant Ethics

48 Ethical Issues in the Supply and Demand of Human Kidneys 425Debra Satz

49 The Survival Lottery 437John Harris

Part VII Experimentation with Human Participants 443

Introduction 445

Human Participants 449

50 Ethics and Clinical Research 451Henry K Beecher

51 Equipoise and the Ethics of Clinical Research 459Benjamin Freedman

52 The Patient and the Public Good 466Samuel Hellman

53 Scientific Research Is a Moral Duty 471John Harris

54 Participation in Biomedical Research Is an Imperfect Moral Duty A Response to John Harris 483Sandra Shapshay and Kenneth D Pimple

Contents ix

55 Unethical Trials of Interventions to Reduce Perinatal Transmission of the Human Immunodeficiency Virus in Developing Countries 489Peter Lurie and Sidney M Wolfe

56 Wersquore Trying to Help Our Sickest People Not Exploit Them 495Danstan Bagenda and Philippa Musoke‐Mudido

57 Medical Researchersrsquo Ancillary Clinical Care Responsibilities 497Leah Belsky and Henry S Richardson

Human Embryos ndash Stem Cells 503

58 President Discusses Stem Cell Research 505George W Bush

59 Killing Embryos for Stem Cell Research 508Jeff McMahan

Part VIII Experimentation with Animals 521

Introduction 523

60 Duties towards Animals 527Immanuel Kant

61 A Utilitarian View 529Jeremy Bentham

62 All Animals Are Equal 530Peter Singer

63 Vivisection Morals and Medicine An Exchange 540R G Frey and Sir William Paton

Part IX Public Health Issues 551

Introduction 553

64 Ethics and Infectious Disease 555Michael J Selgelid

65 Rethinking Mandatory HIV Testing during Pregnancy in Areas with High HIV Prevalence Rates Ethical and Policy Issues 565Udo Schuumlklenk and Anita Kleinsmidt

66 Mandatory HIV Testing in Pregnancy Is There Ever a Time 572Russell Armstrong

67 XDR‐TB in South Africa No Time for Denial or Complacency 582Jerome Amir Singh Ross Upshur and Nesri Padayatchi

x contents

Part X Ethical Issues in the Practice of Healthcare 591

Introduction 593

Confidentiality 597

68 Confidentiality in Medicine A Decrepit Concept 599Mark Siegler

69 The Duty to Warn and Clinical Ethics Legal and Ethical Aspects of Confidentiality and HIVAIDS 603Christian Saumlfken and Andreas Frewer

Truth-Telling 611

70 On a Supposed Right to Lie from Altruistic Motives 613Immanuel Kant

71 Should Doctors Tell the Truth 615Joseph Collins

72 On Telling Patients the Truth 621Roger Higgs

Informed Consent and Patient Autonomy 629

73 On Liberty 631John Stuart Mill

74 From Schloendorff v NewYork Hospital 634Justice Benjamin N Cardozo

75 Informed Consent Its History Meaning and Present Challenges 635Tom L Beauchamp

76 The DoctorndashPatient Relationship in Different Cultures 642Ruth Macklin

77 Amputees by Choice 654Carl Elliott

78 Rational Desires and the Limitation of Life‐Sustaining Treatment 665Julian Savulescu

79 The Nocebo Effect of Informed Consent 683Shlomo Cohen

Part XI Special Issues Facing Nurses 693

Introduction 695

80 The Relation of the Nurse to the Doctor and the Doctor to the Nurse 699Sarah E Dock

81 In Defense of the Traditional Nurse 700Lisa H Newton

Contents xi

82 Patient Autonomy and Medical Paternity Can Nurses Help Doctors to Listen to Patients 708Sarah Breier

83 Health and Human Rights Advocacy Perspectives from a Rwandan Refugee Camp 718Carol Pavlish Anita Ho and Ann‐Marie Rounkle

Part XII Neuroethics 729

Introduction 731

84 Neuroethics An Agenda for Neuroscience and Society 733Jonathan D Moreno

85 How Electrical Brain Stimulation Can Change the Way We Think 741Sally Adee

86 Neuroethics Ethics and the Sciences of the Mind 744Neil Levy

87 Freedom of Memory Today 749Adam Kolber

88 Towards Responsible Use of Cognitive‐Enhancing Drugs by the Healthy 753Henry Greely Barbara Sahakian John Harris Ronald C Kessler Michael Gazzaniga Philip Campbell and Martha J Farah

89 Engineering Love 760Julian Savulescu and Anders Sandberg

Index 762

Acknowledgments

The editor and publisher gratefully acknowledge the permission granted to reproduce the copyright material in this book

1 John Finnis ldquoAbortion and Health Care Ethicsrdquo pp 547ndash57 from Raanan Gillon (ed) Principles of Health Care Ethics Chichester John Wiley 1994 Reproduced with permission from John Wiley amp Sons

2 Michael Tooley ldquoAbortion and Infanticiderdquo pp 37ndash65 from Philosophy and Public Affairs 1 (1972) Reproduced with permission from John Wiley amp Sons

3 Judith Jarvis Thomson ldquoA Defense of Abortionrdquo pp 47ndash66 from Philosophy and Public Affairs 1 1 (1971) Reproduced with permission from John Wiley amp Sons

4 Don Marquis ldquoWhy Abortion Is Immoralrdquo Journal of Philosophy 86 4 (April 1989) 183ndash202

5 Gregory Pence ldquoMultiple Gestation and Damaged Babies Godrsquos Will or Human Choicerdquo This essay draws on ldquoThe McCaughey Septuplets Godrsquos Will or Human Choicerdquo pp 39ndash43 from Gregory Pence Brave New Bioethics Lanham MD Rowman amp Littlefield 2002 copy Gregory Pence 2002 Courtesy of G Pence

6 Dorothy A Greenfeld and Emre Seli ldquoAssisted Reproduction in Same Sex Couplesrdquo pp 289ndash301 from M V Sauer (ed) Principles of Oocyte and Embryo Donation Springer‐Verlag 2013 With kind permisshysion from Springer Science+Business Media

7 Derek Parfit ldquoRights Interests and Possible Peoplerdquo pp 369ndash75 from Samuel Gorovitz et al (eds) Moral

Problems in Medicine Englewood Cliffs NJ Prentice Hall 1976 Courtesy of D Parfit

8 Ruby Catsanos Wendy Rogers and Mianna Lotz ldquoThe Ethics of Uterus Transplantationrdquo pp 65ndash73 from Bioethics 27 2 (2013) Reproduced by permission of John Wiley amp Sons

9 Laura M Purdy ldquoGenetics and Reproductive Risk Can Having Children be Immoralrdquo pp 39ndash49 from Reproducing Persons Issues in Feminist Bioethics Ithaca NY Cornell University Press 1996 Reproduced with permission from Cornell University Press

10 Adrienne Asch ldquoPrenatal Diagnosis and Selective Abortion A Challenge to Practice and Policyrdquo pp 1649ndash57 from American Journal of Public Health 89 11 (1999) Reproduced with permisshysion from American Public Health Association

11 Ruth Chadwick and Mairi Levitt ldquoGenetic Technology A Threat to Deafnessrdquo pp 209ndash15 from Medicine Healthcare and Philosophy 1 (1998) With kind permission from Springer Science+ Business Media

12 The Ethics Committee of the American Society of Reproductive Medicine ldquoSex Selection and Preimplantation Genetic Diagnosisrdquo pp 595ndash8 from Fertility and Sterility 72 4 (October 1999) Reprinted with permission from Elsevier

13 Julian Savulescu and Edgar Dahl ldquoSex Selection and Preimplantation Diagnosis A Response to the Ethics Committee of the American Society of Reproductive Medicinerdquo pp 1879ndash80 from Human Reproduction 15 9 (2000) By permission of Oxford University Press

Acknowledgments xiii

14 John A Robertson Jeffrey P Kahn and John E Wagner ldquoConception to Obtain Hematopoietic Stem Cellsrdquo pp 34ndash40 from Hastings Center Report 32 3 (MayJune 2002) Reproduced with permission from John Wiley amp Sons

15 David King ldquoWhy We Should Not Permit Embryos to Be Selected as Tissue Donorsrdquo pp 13ndash16 from The Bulletin of Medical Ethics 190 (August 2003) Copyright copy RSM Press 2003 Reproduced by permission of SAGE Publications Ltd London Los Angeles New Delhi Singapore and Washington DC

16 Michael Tooley ldquoThe Moral Status of the Cloning of Humansrdquo pp 67ndash101 from James M Humber and Robert I Almeder (eds) Human Cloning Totowa NJ Humana Press 1998 With kind permission from Springer Science+Business Media

17 Jonathan Glover ldquoQuestions about Some Uses of Genetic Engineeringrdquo pp 25ndash33 33ndash6 42ndash3 and 45ndash53 from What Sort of People Should There Be Harmondsworth Penguin Books 1984 Reproshyduced by permission of Penguin Books Ltd

18 David B Resnik ldquoThe Moral Significance of the TherapyndashEnhancement Distinction in Human Geneticsrdquo pp 365ndash77 from Cambridge Quarterly of Healthcare Ethics 9 3 (Summer 2000) copy Cambridge University Press Reproduced with permission

19 Ainsley Newson and Robert Williamson ldquoShould We Undertake Genetic Research on Intelligencerdquo pp 327ndash42 from Bioethics 13 34 (1999) Reproduced with permission from John Wiley amp Sons

20 Nick Bostrom ldquoIn Defense of Posthuman Dignityrdquo pp 202ndash14 from Bioethics 19 3 (2005) Reproduced with permission from John Wiley amp Sons

21 Jonathan Glover ldquoThe Sanctity of Liferdquo pp 39ndash59 from Causing Death and Lives London Pelican 1977 Reproduced by permission of Penguin Books Ltd

22 Sacred Congregation for the Doctrine of the Faith ldquoDeclaration on Euthanasiardquo Vatican City 1980

23 Germain Grisez and Joseph M Boyle Jr ldquoThe Morality of Killing A Traditional Viewrdquo

pp 381ndash419 from Life and Death with Liberty and Justice A Contribution to the Euthanasia Debate Notre Dame IN University of Notre Dame Press 1971

24 James Rachels ldquoActive and Passive Euthanasiardquo pp 78ndash80 from New England Journal of Medicine 292 (1975) Copyright copy 1975 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

25 Winston Nesbitt ldquoIs Killing No Worse Than Letting Dierdquo pp 101ndash5 from Journal of Applied Philosophy 12 1 (1995) Reproduced with permission from John Wiley amp Sons

26 Helga Kuhse ldquoWhy Killing Is Not Always Worse ndash and Sometimes Better ndash Than Letting Dierdquo pp 371ndash4 from Cambridge Quarterly of Healthcare 7 4 (1998) copy Cambridge University Press Reproduced with permission

27 Franklin G Miller Robert D Truog and Dan W Brock ldquoMoral Fictions and Medical Ethicsrdquo pp 453ndash60 from Bioethics 24 9 (2010) Reproduced with permission from John Wiley amp Sons

28 Neil Campbell ldquoWhen Care Cannot Cure Medical Problems in Seriously Ill Babiesrdquo pp 327ndash44 from F K Beller and R F Weir (eds) The Beginning of Human Life Dordrecht Kluwer Academic Publishers 1994 With kind pershymission from Springer Science+Business Media

29 R M Hare ldquoThe Abnormal Child Moral Dilemmas of Doctors and Parentsrdquo Reprinted in Essays on Bioethics Oxford Clarendon Press 1993 pp185ndash91 Courtesy of the Estate of R M Hare

30 Alison Davis ldquoRight to Life of Handicappedrdquo p 181 from Journal of Medical Ethics 9 (1983) Reproduced with permission from BMJ Publishing Group

31 Christine Overall ldquoConjoined Twins Embodied Personhood and Surgical Separationrdquo pp 69ndash84 from L Tessman (ed) Feminist Ethics and Social and Political Philosophy Theorizing the Non‐Ideal Springer 2009 With kind permission from Springer Science+Business Media

32 Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death ldquolsquoA Definition of Irreversible Comarsquo Report to Examine the Definition of Brain

xiv acknowledgments

Deathrdquo pp 85ndash8 from Journal of the American Medical Association 205 6 (August 1968) Copyright copy 1968 American Medical Association All rights reserved

33 Ari Joffe ldquoAre Recent Defences of the Brain Death Concept Adequaterdquo pp 47ndash53 from Bioethics 24 2 (February 2010) Reproduced with permission from John Wiley amp Sons

34 Peter Singer ldquoIs the Sanctity of Life Ethic Terminally Illrdquo pp 307ndash43 from Bioethics 9 34 (1995) Reproduced with permission from John Wiley amp Sons

35 Ronald Dworkin ldquoLife Past Reasonrdquo pp 218ndash29 from Lifersquos Dominion An Argument about Abortion Euthanasia and Individual Freedom New York Knopf 1993 Copyright copy 1993 by Ronald Dworkin Used by permission of Alfred A Knopf an imprint of the Knopf Doubleday Publishing Group a division of Random House LLC All rights reserved

36 Rebecca Dresser ldquoDworkin on Dementia Elegant Theory Questionable Policyrdquo pp 32ndash8 from Hastings Center Report 25 6 (NovemberDecember 1995) Reproduced with permission from John Wiley amp Sons

37 Chris Hill ldquoThe Noterdquo pp 9ndash17 from Helga Kuhse (ed) Willing to Listen Wanting to Die Ringwood Australia Penguin Books 1994

38 Daniel Callahan ldquoWhen Self‐Determination Runs Amokrdquo pp 52ndash5 from Hastings Center Report 22 2 (MarchApril 1992) Reproduced with permission from John Wiley amp Sons

39 John Lachs ldquoWhen Abstract Moralizing Runs Amokrdquo pp 10ndash13 from The Journal of Clinical Ethics 5 1 (Spring 1994) Copyright JCE

40 Bregje D Onwuteaka‐Philipsen et al ldquoTrends in End‐Of‐Life Practices Before and After the Enactment of the Euthanasia Law in the Netherlands from 1990 to 2010 A Repeated Cross‐Sectional Surveyrdquo pp 908ndash15 from The Lancet 380 9845 (2012) Reprinted from The Lancet with permission from Elsevier

41 Bernard Lo ldquoEuthanasia in the Netherlands What Lessons for Elsewhererdquo pp 869ndash70 from The Lancet 380 (September 8 2012) Copyright 2012 Reprinted from The Lancet with permisshysion from Elsevier

42 Paul T Menzel ldquoRescuing Lives Canrsquot We Countrdquo pp 22ndash3 from Hastings Center Report 24 1 (1994) Reproduced with permission from John Wiley amp Sons

43 Alvin H Moss and Mark Siegler ldquoShould Alcoholics Compete Equally for Liver Transshyplantationrdquo pp 1295ndash8 from Journal of the American Medical Association 265 10 (1991) Copyright copy 1991 American Medical Association All rights reserved

44 John Harris ldquoThe Value of Liferdquo pp 87ndash102 from The Value of Life London Routledge 1985 Copyright 1985 Routledge Reproduced by permission of Taylor amp Francis Books UK

45 Nick Beckstead and Toby Ord ldquoBubbles under the Wallpaper Healthcare Rationing and Disshycriminationrdquo a paper presented to the confershyence ldquoValuing Livesrdquo New York University March 5 2011 copy Nick Beckstead and Toby Ord reprinted by permission of the authors This paper is published here for the first time but draws on Nick Beckstead and Toby Ord ldquoRationing and Rationality The Cost of Avoiding Discriminationrdquo in N Eyal et al (eds) Inequalities in Health Concepts Measures and Ethics Oxford Oxford University Press 2013 pp 232ndash9 By permission of Oxford University Press

46 Eike‐Henner W Kluge ldquoOrgan Donation and Retrieval Whose Body Is It Anywayrdquo copy 1999 by Eike‐Henner W Kluge

47 Janet Radcliffe‐Richards et al ldquoThe Case for Allowing Kidney Salesrdquo pp 1950ndash2 from The Lancet 351 9120 (June 27 1998) Reprinted with permission from Elsevier

48 Debra Satz ldquoEthical Issues in the Supply and Demand of Human Kidneysrdquo pp 189ndash206 from Why Some Things Should Not Be for Sale The Moral Limits of Markets New York Oxford University Press 2010 ch 9 based on an article from Proceedings of the Aristotelian Society Reprinted by courtesy of the Editor of Proceedings of the Aristotelian Society copy 2010

49 John Harris ldquoThe Survival Lotteryrdquo pp 81ndash7 from Philosophy 50 (1975) copy Royal Institute of Philosophy published by Cambridge University Press Reproduced with permission

Acknowledgments xv

50 Henry K Beecher ldquoEthics and Clinical Researchrdquo pp 1354ndash60 from New England Journal of Medicine 274 24 (June 1966) Copyright copy 1996 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

51 Benjamin Freedman ldquoEquipoise and the Ethics of Clinical Researchrdquo pp 141ndash5 from New England Journal of Medicine 317 3 (July 1987) Copyright copy 1987 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

52 Samuel Hellman ldquoThe Patient and the Public Goodrdquo pp 400ndash2 from Nature Medicine 1 5 (1995) Reprinted by permission from Macmillan Publishers Ltd

53 John Harris ldquoScientific Research Is a Moral Dutyrdquo pp 242ndash8 from Journal of Medical Ethics 31 4 (2005) Reproduced with permission from BMJ Publishing Group

54 Sandra Shapshay and Kenneth D Pimple ldquoParticipation in Research Is an Imperfect Moral Duty A Response to John Harrisrdquo pp 414ndash17 from Journal of Medical Ethics 33 (2007) Reproduced with permission from BMJ Publishing Group

55 Peter Lurie and Sidney M Wolfe ldquoUnethical Trials of Interventions to Reduce Perinatal Transmission of the Human Immunodeficiency Virus in Developing Countriesrdquo pp 853ndash6 from New England Journal of Medicine 337 12 (September 1997) Copyright copy 1997 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

56 Danstan Bageda and Philippa Musoke‐Mudido ldquoWersquore Trying to Help Our Sickest People Not Exploit Themrdquo from The Washington Post September 28 1997 copy 1997 Washington Post Company All rights reserved Used by permisshysion and protected by the Copyright Laws of the United States The printing copying redistribushytion or retransmission of this Content without express written permission is prohibited

57 Leah Belsky and Henry S Richardson ldquoMedical Researchersrsquo Ancillary Clinical Care Respon sibilitiesrdquo pp 1494ndash6 from British

Medical Journal 328 (June 19 2004) Reproduced with permission from BMJ Publishing Group

58 George W Bush ldquoPresident Discusses Stem Cell Researchrdquo Office of the Press Secretary White House August 9 2001

59 Jeff McMahan ldquoKilling Embryos for Stem Cell Researchrdquo pp 170ndash89 from Metaphilosophy 38 23 (2007) Reproduced with permission from John Wiley amp Sons

60 Immanuel Kant ldquoDuties towards Animalsrdquo pp 239ndash41 from Lectures on Ethics trans Louis Infield London Methuen 1930 Copyright 1930 Methuen reproduced by permission of Taylor amp Francis Books UK

61 Jeremy Bentham ldquoA Utilitarian Viewrdquo section XVIII IV from An Introduction to the Principles of Morals and Legislation First published c1820

62 Peter Singer ldquoAll Animals are Equalrdquo pp 103ndash16 from Philosophic Exchange 1 5 (1974) Center for Philosophic Exchange State University of New York Brockford NY 1974

63 R G Frey and Sir William Paton ldquoVivisection Morals and Medicine An Exchangerdquo pp 94ndash7 and 102ndash4 from Journal of Medical Ethics 9 (1983) Reproduced with permission from BMJ Publishing Group

64 Michael J Selgelid ldquoEthics and Infectious Diseaserdquo pp 272ndash89 from Bioethics 19 3 (2005) Reproduced with permission from John Wiley amp Sons

65 Udo Schuumlklenk and Anita Kleinsmidt ldquoRethinking Mandatory HIV Testing during Pregnancy in Areas with High HIV Prevalence Rates Ethical and Policy Issuesrdquo pp 1179ndash83 from American Journal of Public Health 97 7 (2007) Reproduced with permission from American Public Health Association

66 Russell Armstrong ldquoMandatory HIV Testing in Pregnancy Is There Ever a Timerdquo pp 1ndash10 from Developing World Bioethics 8 1 (2008) Reproduced with permission from John Wiley amp Sons

67 Jerome Amir Singh Ross Upshur and Nesri Padayatchi ldquoXDR‐TB in South Africa No Time for Denial or Complacencyrdquo PLoS Med 4 1 (2007) e50 doi101371journalpmed0040050 Copyright copy 2007 Singh et al

xvi acknowledgments

68 Mark Siegler ldquoConfidentiality in Medicine A Decrepit Conceptrdquo pp 1518ndash21 from New England Journal of Medicine 307 24 (December 1982) Copyright copy 1982 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

69 Christian Saumlfken and Andreas Frewer ldquoThe Duty to Warn and Clinical Ethics Legal and Ethical Aspects of Confidentiality and HIVAIDSrdquo pp 313ndash326 from HEC Forum 19 4 (2007) With kind permission from Springer Science+Business Media

70 Immanuel Kant ldquoOn a Supposed Right to Lie from Altruistic Motivesrdquo pp 361ndash3 from Critique of Practical Reason and Other Works on the Theory of Ethics 6th edition trans T K Abbott London 1909 This essay was first published in a Berlin periodical in 1797

71 Joseph Collins ldquoShould Doctors Tell the Truthrdquo pp 320ndash6 from Harperrsquos Monthly Magazine 155 (August 1927) Copyright copy 1927 Harperrsquos Magazine All rights reserved Reproduced from the August issue by special permission

72 Roger Higgs ldquoOn Telling Patients the Truthrdquo pp 186ndash202 and 232ndash3 from Michael Lockwood (ed) Moral Dilemmas in Modern Medicine Oxford Oxford University Press 1985 By permission of Oxford University Press

73 John Stuart Mill ldquoOn Libertyrdquo first published in 1859

74 Justice Benjamin N Cardozo Judgment from Schloendorff v New York Hospital (1914) p 526 from Jay Katz (ed) Experimentation with Human Beings The Authority of the Investigator Subject Professions and State in the Human Experimentation Process New York Russell Sage Foundation 1972 Reproduced with permission of Russell Sage Foundation

75 Tom L Beauchamp ldquoInformed Consent Its History Meaning and Present Challengesrdquo pp 515ndash23 from Cambridge Quarterly of Health Care Ethics 20 4 (2011) copy Royal Institute of Philosophy published by Cambridge University Press Reproduced with permission from Cambridge University Press and T Beauchamp

76 Ruth Macklin ldquoThe DoctorndashPatient Relationshyship in Different Culturesrdquo pp 86ndash107 from

Against Relativism Cultural Diversity and the Search of Ethical Universals in Medicine copy 1999 by Oxford University Press Inc By permission of Oxford University Press USA

77 Carl Elliott ldquoAmputees by Choicerdquo pp 208ndash10 210ndash15 219ndash23 227ndash31 234ndash6 323ndash6 from Better Than Well American Medicine Meets the American Dream New York and London WW Norton 2003 Copyright copy 2003 by Carl Elliott Used by permission of W W Norton amp Company Inc

78 Julian Savulescu ldquoRational Desires and the Limishytation of Life‐Sustaining Treatmentrdquo pp 191ndash 222 from Bioethics 8 3 (1994) Reproduced with permission from John Wiley amp Sons

79 Shlomo Cohen ldquoThe Nocebo Effect of Informed Consentrdquo pp 147ndash54 from Bioethics 28 3 (2014) Reproduced with permission from John Wiley amp Sons

80 Sarah E Dock ldquoThe Relation of the Nurse to the Doctor and the Doctor to the Nurserdquo p 394 (extract) from The American Journal of Nursing 17 5 (1917)

81 Lisa H Newton ldquoIn Defense of the Traditional Nurserdquo pp 348ndash54 from Nursing Outlook 29 6 (1981) Copyright Elsevier 1981

82 Sarah Breier ldquoPatient Autonomy and Medical Paternity Can Nurses Help Doctors to Listen to Patientsrdquo pp 510ndash21 from Nursing Ethics 8 6 (2001) Reproduced with permission from Sage and S Breier

83 Carol Pavlish Anita Ho and Ann‐Marie Rounkle ldquoHealth and Human Rights Advocacy Perspectives from a Rwandan Refugee Camprdquo pp 538ndash49 from Nursing Ethics 19 4 (2012) Copyright copy 2012 by SAGE Publications Reprinted by Permission of SAGE

84 Jonathan D Moreno ldquoNeuroethics An Agenda for Neuroscience and Societyrdquo pp 149ndash53 from Nature Reviews 4 (February 2003)Reprinted by permission from Macmillan Publishers Ltd

85 Sally Adee ldquoHow Electrical Brain Stimulation Can Change the Way We Thinkrdquo The Week March 30 2012

86 Neil Levy ldquoNeuroethics Ethics and the Sciences of the Mindrdquo pp 69ndash74 (extract) from Philosophy

Acknowledgments xvii

Compass 4 10 (2009) pp 69ndash81 Reproduced with permission from John Wiley amp Sons

87 Adam Kolber ldquoFreedom of Memory Todayrdquo pp 145ndash8 from Neuroethics 1 (2008) With kind permission from Springer Science+Business Media

88 Henry Greely and Colleagues ldquoTowards Responsible Use of Cognitive‐Enhancing Drugs

by the Healthyrdquo pp 702ndash5 from Nature 456 (December 11 2008) Reprinted by permission from Macmillan Publishers Ltd

89 Julian Savulescu and Anders Sandberg ldquoEngineering LoverdquoldquoLove Machine Engineering Lifelong Romancerdquo pp 28ndash9 from New Scientist 2864 copy 2012 Reed Business Information ndash UK All rights reserved Distributed by Tribune Content Agency

Bioethics An Anthology Third Edition Edited by Helga Kuhse Udo Schuumlklenk and Peter Singer copy 2016 John Wiley amp Sons Inc Published 2016 by John Wiley amp Sons Inc

Introduction

The term ldquobioethicsrdquo was coined by Van Rensselaer Potter who used it to describe his proposal that we need an ethic that can incorporate our obligations not just to other humans but to the biosphere as a whole1 Although the term is still occasionally used in this sense of an ecological ethic it is now much more commonly used in the narrower sense of the study of ethical issues arising from the biological and medical sciences So understood bioethics has become a specialized although interdisciplinary area of study The essays included in this book give an indication of the range of issues which fall within its scope ndash but it is only an indication There are many other issues that we simply have not had the space to cover

Bioethics can be seen as a branch of ethics or more specifically of applied ethics For this reason some understanding of the nature of ethics is an essential preliminary to any serious study of bioethics The remainder of this introduction will seek to provide that understanding

One question about the nature of ethics is especially relevant to bioethics to what extent is reasoning or argument possible in ethics Many people assume without much thought that ethics is subjective The subjectivist holds that what ethical view we take is a matter of opinion or taste that is not amenable to argument But if ethics were a matter of taste why would we even attempt to argue about it If Helen says ldquoI like my coffee sweetenedrdquo whereas Paul says

ldquoI like my coffee unsweetenedrdquo there is not much point in Helen and Paul arguing about it The two statements do not contradict each other They can both be true But if Helen says ldquoDoctors should never assist their patients to dierdquo whereas Paul says ldquoSometimes doctors should assist their patients to dierdquo then Helen and Paul are disagreeing and there does seem to be a point in their trying to argue about the issue of physician‐assisted suicide

It seems clear that there is some scope for argument in ethics If I say ldquoIt is always wrong to kill a human beingrdquo and ldquoAbortion is not always wrongrdquo then I am committed to denying that abortion kills a human being Otherwise I have contradicted myself and in doing so I have not stated a coherent position at all So consistency at least is a requirement of any defensible ethical position and thus sets a limit to the subjectivity of ethical judgments The requirement of factual accuracy sets another limit In discussing issues in bioethics the facts are often complex But we cannot reach the right ethical decisions unless we are well‐informed about the relevant facts In this respect ethical decisions are unlike decisions of taste We can enjoy a taste without knowing what we are eating but if we assume that it is wrong to resuscitate a terminally ill patient against her wishes then we can-not know whether an instance of resuscitation was morally right or wrong without knowing something about the patientrsquos prognosis and whether the patient

2 introduction

has expressed any wishes about being resuscitated In that sense there is no equivalent in ethics to the immediacy of taste

Ethical relativism sometimes also known as cul-tural relativism is one step away from ethical sub-jectivism but it also severely limits the scope of ethical argument The ethical relativist holds that it is not individual attitudes that determine what is right or wrong but the attitudes of the culture in which one lives Herodotus tells how Darius King of Persia summoned the Greeks from the western shores of his kingdom before him and asked them how much he would have to pay them to eat their fathersrsquo dead bodies They were horrified by the idea and said they would not do it for any amount of money for it was their custom to cremate their dead Then Darius called upon Indians from the eastern frontiers of his kingdom and asked them what would make them willing to burn their fathersrsquo bodies They cried out and asked the King to refrain from mentioning so shocking an act Herodotus comments that each nation thinks its own customs best From here it is only a short step to the view that there can be no objective right or wrong beyond the bounds of onersquos own culture This view found increased support in the nine-teenth century as Western anthropologists came to know many different cultures and were impressed by ethical views very different from those that were standardly taken for granted in European society As a defense against the automatic assumption that Western morality is superior and should be imposed on ldquosavagesrdquo many anthropologists argued that since morality is relative to culture no culture can have any basis for regarding its morality as superior to any other culture

Although the motives with which anthropolo-gists put this view forward were admirable they may not have appreciated the implications of the position they were taking The ethical relativist maintains that a statement like ldquoIt is good to enslave people from another tribe if they are captured in warrdquo means simply ldquoIn my society the custom is to enslave people from another tribe if they are cap-tured in warrdquo Hence if one member of the society were to question whether it really was good to enslave people in these circumstances she could be

answered simply by demonstrating that this was indeed the custom ndash for example by showing that for many generations it had been done after every war in which prisoners were captured Thus there is no way for moral reformers to say that an accepted custom is wrong ndash ldquowrongrdquo just means ldquoin accord-ance with an accepted customrdquo

On the other hand when people from two different cultures disagree about an ethical issue then according to the ethical relativist there can be no resolution of the disagreement Indeed strictly there is no disagree-ment If the apparent dispute were over the issue just mentioned then one person would be saying ldquoIn my country it is the custom to enslave people from another tribe if they are captured in warrdquo and the other person would be saying ldquoIn my country it is not the custom to allow one human being to enslave anotherrdquo This is no more a disagreement than such statements as ldquoIn my country people greet each other by rubbing nosesrdquo and ldquoIn my country people greet each other by shaking handsrdquo If ethical relativism is true then it is impossible to say that one culture is right and the other is wrong Bearing in mind that some cultures have practiced slavery or the burning of widows on the funeral pyre of their husbands this is hard to accept

A more promising alternative to both ethical subjectivism and cultural relativism is universal pre-scriptivism an approach to ethics developed by the Oxford philosopher R M Hare Hare argues that the distinctive property of ethical judgments is that they are universalizable In saying this he means that if I make an ethical judgment I must be prepared to state it in universal terms and apply it to all relevantly similar situations By ldquouniversal termsrdquo Hare means those terms that do not refer to a particular individual Thus a proper name cannot be a universal term If for example I were to say ldquoEveryone should do what is in the interests of Mick Jaggerrdquo I would not be making a universal judgment because I have used a proper name The same would be true if I were to say that everyone must do what is in my interests because the personal pronoun ldquomyrdquo is here used to refer to a particular individual myself

It might seem that ruling out particular terms in this way does not take us very far After all one can always describe oneself in universal terms Perhaps

Introduction 3

I canrsquot say that everyone should do what is in my interests but I could say that everyone must do whatever is in the interests of people who hellip and then give a minutely detailed description of myself including the precise location of all my freckles The effect would be the same as saying that everyone should do what is in my interests because there would be no one except me who matches that description But Hare meets this problem very effectively by saying that to prescribe an ethical judgment universally means being prepared to pre-scribe it for all possible circumstances including hypothetical ones So if I were to say that everyone should do what is in the interests of a person with a particular pattern of freckles I must be prepared to prescribe that in the hypothetical situation in which I do not have this pattern of freckles but someone else does I should do what is in the interests of that person Now of course I may say that I should do that since I am confident that I shall never be in such a situation but this simply means that I am being dishonest I am not genuinely prescribing the principle universally

The effect of saying that an ethical judgment must be universalizable for hypothetical as well as actual circumstances is that whenever I make an ethical judgment I can be challenged to put myself in the position of the parties affected and see if I would still be able to accept that judgment Suppose for example that I own a small factory and the cheapest way for me to get rid of some waste is to pour it into a nearby river I do not take water from this river but I know that some villagers living downstream do and the waste may make them ill The requirement that ethical judgments should be universalizable will make it difficult for me to justify my conduct because if I imagine myself in the hypothetical situation of being one of the villagers rather than the factory‐owner I would not accept that the profits of the factory‐owner should outweigh the risk of adverse effects on my health and that of my children In this way Harersquos approach requires us to take into account the interests and preferences of all others affected by our actions Hence it allows for an element of reasoning in ethical deliberation

Since the rightness or wrongness of our actions will on this view depend on the way in which they

affect others Harersquos universal prescriptivism leads to a form of consequentialism ndash that is the view that the rightness of an action depends on its consequences The best‐known form of consequentialism is the clas-sical utilitarianism developed in the late eighteenth century by Jeremy Bentham and popularized in the nineteenth century by John Stuart Mill They held that an action is right if it leads to a greater surplus of happiness over misery than any possible alternative and wrong if it does not By ldquogreater surplus of happinessrdquo the classical utilitarians had in mind the idea of adding up all the pleasure or happiness that resulted from the action and subtracting from that total all the pain or misery to which the action gave rise Naturally in some circumstances it might be possible only to reduce misery and then the right action should be understood as the one that will result in less misery than any possible alternative

The utilitarian view is striking in many ways It puts forward a single principle that it claims can provide the right answer to all ethical dilemmas if only we can predict what the consequences of our actions will be It takes ethics out of the mysterious realm of duties and rules and bases ethical decisions on something that almost everyone understands and values Moreover utilitarianismrsquos single principle is applied universally without fear or favor Bentham said ldquoEach to count for one and none for more than onerdquo by which he meant that the happiness of a com-mon tramp counted for as much as that of a noble and the happiness of an African was no less important than that of a European

Many contemporary consequentialists agree with Bentham to the extent that they think the rightness or wrongness of an action must depend on its conse-quences but they have abandoned the idea that m aximizing net happiness is the ultimate goal Instead they argue that we should seek to bring about w hatever will satisfy the greatest number of desires or preference This variation which is known as ldquop reference utilitarianismrdquo does not regard anything as good except in so far as it is wanted or desired More intense or strongly held preferences would get more weight than weak preferences

Consequentialism offers one important answer to the question of how we should decide what is right and what is wrong but many ethicists reject it The

4 introduction

denial of this view was dramatically presented by Dostoevsky in The Karamazov Brothers

imagine that you are charged with building the edifice of human destiny the ultimate aim of which is to bring people happiness to give them peace and contentment at last but that in order to achieve this it is essential and unavoidable to torture just one little speck of creation that same little child beating her chest with her little fists and imagine that this edifice has to be erected on her unexpiated tears Would you agree to be the architect under those conditions Tell me honestly2

The passage suggests that some things are always wrong no matter what their consequences This has for most of Western history been the prevailing approach to morality at least at the level of what has been officially taught and approved by the institutions of Church and State The ten commandments of the Hebrew scriptures served as a model for much of the Christian era and the Roman Catholic Church built up an elaborate system of morality based on rules to which no exceptions were allowed

Another example of an ethic of rules is that of Immanuel Kant Kantrsquos ethic is based on his ldquocategori-cal imperativerdquo which he states in several distinct for-mulations One is that we must always act so that we can will the maxim of our action to be a universal law This can be interpreted as a form of Harersquos idea of universalizability which we have already encountered Another is that we must always treat other people as ends never as means While these formulations of the categorical imperative might be applied in various ways in Kantrsquos hands they lead to inviolable rules for example against making promises that we do not intend to keep Kant also thought that it was always wrong to tell a lie In response to a critic who sug-gested that this rule has exceptions Kant said that it would be wrong to lie even if someone had taken refuge in your house and a person seeking to murder him came to your door and asked if you knew where he was Modern Kantians often reject this hard-line approach to rules and claim that Kantrsquos categorical imperative did not require him to hold so strictly to the rule against lying

How would a consequentialist ndash for example a classical utilitarian ndash answer Dostoevskyrsquos challenge If answering honestly ndash and if one really could be certain

that this was a sure way and the only way of bringing lasting happiness to all the people of the world ndash utilitarians would have to say yes they would accept the task of being the architect of the happiness of the world at the cost of the childrsquos unexpiated tears For they would point out that the suffering of that child wholly undeserved as it is will be repeated a million‐fold over the next century for other children just as innocent who are victims of starvation disease and brutality So if this one child must be sacrificed to stop all this suffering then terrible as it is the child must be sacrificed

Fantasy apart there can be no architect of the hap-piness of the world The world is too big and complex a place for that But we may attempt to bring about less suffering and more happiness or satisfaction of preferences for people or sentient beings in specific places and circumstances Alternatively we might fol-low a set of principles or rules ndash which could be of varying degrees of rigidity or flexibility Where would such rules come from Kant tried to deduce them from his categorical imperative which in turn he had reached by insisting that the moral law must be based on reason alone without any content from our wants or desires But the problem with trying to deduce morality from reason alone has always been that it becomes an empty formalism that cannot tell us what to do To make it practical it needs to have some addi-tional content and Kantrsquos own attempts to deduce rules of conduct from his categorical imperative are unconvincing

Others following Aristotle have tried to draw on human nature as a source of moral rules What is good they say is what is natural to human beings They then contend that it is natural and right for us to seek certain goods such as knowledge friendship health love and procreation and unnatural and wrong for us to act contrary to these goods This ldquonatural lawrdquo ethic is open to criticism on several points The word ldquonaturalrdquo can be used both descriptively and evalua-tively and the two senses are often mixed together so that value judgments may be smuggled in under the guise of a description The picture of human nature presented by proponents of natural law ethics usually selects only those characteristics of our nature that the proponent considers desirable The fact that our species especially its male members frequently go to war and

Introduction 5

are also prone to commit individual acts of violence against others is no doubt just as much part of our nature as our desire for knowledge but no natural law theorist therefore views these activities as good More generally natural law theory has its origins in an Aristotelian idea of the cosmos in which everything has a goal or ldquoendrdquo which can be deduced from its nature The ldquoendrdquo of a knife is to cut the assumption is that human beings also have an ldquoendrdquo and we will flourish when we live in accordance with the end for which we are suited But this is a pre‐Darwinian view of nature Since Darwin we know that we do not exist for any purpose but are the result of natural selection operating on random mutations over millions of years Hence there is no reason to believe that living accord-ing to nature will produce a harmonious society let alone the best possible state of affairs for human beings

Another way in which it has been claimed that we can come to know what moral principles or rules we should follow is through our intuition In practice this usually means that we adopt conven-tionally accepted moral principles or rules perhaps with some adjustments in order to avoid inconsist-ency or arbitrariness On this view a moral theory should like a scientific theory try to match the data and the data that a moral theory must match is p rovided by our moral intuitions As in science if a plausible theory matches most but not all of the data then the anomalous data might be rejected on the grounds that it is more likely that there was an error in the procedures for gathering that particular set of data than that the theory as a whole is mis-taken But ultimately the test of a theory is its ability to explain the data The problem with applying this model of scientific justification to ethics is that the ldquodatardquo of our moral intuitions is unreliable not just at one or two specific points but as a whole Here the facts that cultural relativists draw upon are rele-vant (even if they do not establish that cultural rela-tivism is the correct response to it) Since we know that our intuitions are strongly influenced by such things as culture and religion they are ill‐suited to serve as the fixed points against which an ethical theory must be tested Even where there is cross‐cultural agreement there may be some aspects of our intuitions on which all cultures unjustifiably favor our own interests over those of others For

example simply because we are all human beings we may have a systematic bias that leads us to give an unjustifiably low moral status to nonhuman a nimals Or because in virtually all known human societies men have taken a greater leadership role than women the moral intuitions of all societies may not adequately reflect the interests of females

Some philosophers think that it is a mistake to base ethics on principles or rules Instead they focus on what it is to be a good person ndash or in the case of the problems with which this book is concerned perhaps on what it is to be a good nurse or doctor or researcher They seek to describe the virtues that a good person or a good member of the relevant profession should possess Moral education then consists of teaching these virtues and discussing how a virtuous person would act in specific situations The question is how-ever whether we can have a notion of what a virtuous person would do in a specific situation without making a prior decision about what it is right to do After all in any particular moral dilemma different virtues may be applicable and even a particular virtue will not always give unequivocal guidance For instance if a terminally ill patient repeatedly asks a nurse or doctor for assistance in dying what response best exemplifies the virtues of a healthcare professional There seems no answer to this question short of an inquiry into whether it is right or wrong to help a patient in such circumstances to die But in that case we seem bound in the end to come back to discuss-ing such issues as whether it is right to follow moral rules or principles or to do what will have the best consequences

In the late twentieth century some feminists offered new criticisms of conventional thought about ethics They argued that the approaches to ethics taken by the influential philosophers of the past ndash all of whom have been male ndash give too much emphasis to abstract principles and the role of reason and give too little attention to personal relationships and the part played by emotion One outcome of these criticisms has been the development of an ldquoethic of carerdquo which is not so much a single ethical theory as a cluster of ways of looking at ethics which put an attitude of c aring for others at the center and seek to avoid r eliance on abstract ethical principles The ethic of care has seemed especially applicable to the work of those

6 introduction

involved in direct patient care and has recently been taken up by a number of nursing theorists as offering a more suitable alternative to other ideas of ethics Not all feminists however support this development Some worry that the adoption of a ldquocarerdquo approach by nurses may reflect and even reinforce stereotypes of women as more emotional and less rational than men They also fear that it could lead to women continuing to carry a disproportionate burden of caring for others to the exclusion of adequately caring for themselves

In this discussion of ethics we have not mentioned anything about religion This may seem odd in view of the close connection that has often been made between religion and ethics but it reflects our belief that despite this historical connection ethics and reli-gion are fundamentally independent Logically ethics is prior to religion If religious believers wish to say that a deity is good or praise her or his creation or deeds they must have a notion of goodness that is independent of their conception of the deity and what she or he does Otherwise they will be saying that the deity is good and when asked what they mean by ldquogoodrdquo they will have to refer back to the deity saying perhaps that ldquogoodrdquo means ldquoin accord-ance with the wishes of the deityrdquo In that case sen-tences such as ldquoGod is goodrdquo would be a meaningless tautology ldquoGod is goodrdquo could mean no more than ldquoGod is in accordance with Godrsquos wishesrdquo As we have already seen there are ideas of what it is for something to be ldquogoodrdquo that are not rooted in any religious belief While religions typically encourage or instruct their followers to obey a particular ethical code it is obvious that others who do not follow any religion can also think and act ethically

To say that ethics is independent of religion is not to deny that theologians or other religious believers may have a role to play in bioethics Religious traditions often have long histories of dealing with ethical dilem-mas and the accumulation of wisdom and experience that they represent can give us valuable insights into particular problems But these insights should be subject to criticism in the way that any other proposals would be If in the end we accept them it is because we have judged them sound not because they are the utterances of a pope a rabbi a mullah or a holy person

Ethics is also independent of the law in the sense that the rightness or wrongness of an act cannot be

settled by its legality or illegality Whether an act is legal or illegal may often be relevant to whether it is right or wrong because it is arguably wrong to break the law other things being equal Many people have thought that this is especially so in a democracy in which everyone has a say in making the law Another reason why the fact that an act is illegal may be a rea-son against doing it is that the legality of an act may affect the consequences that are likely to flow from it If active voluntary euthanasia is illegal then doctors who practice it risk going to jail which will cause them and their families to suffer and also mean that they will no longer be able to help other patients This can be a powerful reason for not practicing voluntary euthanasia when it is against the law but if there is only a very small chance of the offense becoming known or being proved then the weight of this con-sequentialist reason against breaking the law is reduced accordingly Whether we have an ethical obligation to obey the law and if so how much weight should be given to it is itself an issue for ethical argument

Though ethics is independent of the law in the sense just specified laws are subject to evaluation from an ethical perspective Many debates in bioethics focus on questions about what practices should be allowed ndash for example should we allow research on stem cells taken from human embryos sex selection or cloning ndash and committees set up to advise on the ethical social and legal aspects of these questions often recommend legislation to prohibit the activity in question or to allow it to be practiced under some form of regulation Discussing a question at the level of law and public policy however raises somewhat different considerations than a discussion of personal ethics because the consequences of adopting a public policy generally have much wider ramifications than the consequences of a personal choice That is why some healthcare professionals feel justified in assisting a terminally ill patient to die while at the same time opposing the legalization of physician‐assisted suicide Paradoxical as this position may appear ndash and it is certainly open to criticism ndash it is not straightforwardly inconsistent

Naturally many of the essays we have selected reflect the times in which they were written Since bioethics often comments on developments in fast‐moving

Introduction 7

areas of medicine and the biological sciences the factual content of articles in bioethics can become obsolete quite rapidly In preparing this revised edition we have taken the opportunity to cover some new issues and to include some more recent writings We have for example included new mate-rial on genetic enhancement as well as on the use of embryonic human stem cells This edition of the anthology also includes new sections on ethical issues in public health and in the neurosciences Nevertheless an article that has dated in regard to its facts often makes ethical points that are still valid

or worth considering so we have not excluded older articles for this reason

Other articles are dated in a different way During the past few decades we have become more sensitive about the ways in which our language may exclude women or reflect our prejudices regarding race or sexuality We see no merit in trying to disguise past practices on such matters so we have not excluded otherwise valuable works in bioethics on these grounds If they are jar-ring to the modern reader that may be a salutary reminder of the extent to which we all are subject to the conventions and prejudices of our times

Notes

1 See Van Rensselaer Potter Bioethics Bridge to the Future (Englewood Cliffs NJ Prentice‐Hall 1971)

2 The Karamazov Brothers trans Ignat Avsey (Oxford Oxford University Press 1994) vol I part 2 bk 5 ch 4 First published in 1879

Abortion

Part I

Contents ix

55 Unethical Trials of Interventions to Reduce Perinatal Transmission of the Human Immunodeficiency Virus in Developing Countries 489Peter Lurie and Sidney M Wolfe

56 Wersquore Trying to Help Our Sickest People Not Exploit Them 495Danstan Bagenda and Philippa Musoke‐Mudido

57 Medical Researchersrsquo Ancillary Clinical Care Responsibilities 497Leah Belsky and Henry S Richardson

Human Embryos ndash Stem Cells 503

58 President Discusses Stem Cell Research 505George W Bush

59 Killing Embryos for Stem Cell Research 508Jeff McMahan

Part VIII Experimentation with Animals 521

Introduction 523

60 Duties towards Animals 527Immanuel Kant

61 A Utilitarian View 529Jeremy Bentham

62 All Animals Are Equal 530Peter Singer

63 Vivisection Morals and Medicine An Exchange 540R G Frey and Sir William Paton

Part IX Public Health Issues 551

Introduction 553

64 Ethics and Infectious Disease 555Michael J Selgelid

65 Rethinking Mandatory HIV Testing during Pregnancy in Areas with High HIV Prevalence Rates Ethical and Policy Issues 565Udo Schuumlklenk and Anita Kleinsmidt

66 Mandatory HIV Testing in Pregnancy Is There Ever a Time 572Russell Armstrong

67 XDR‐TB in South Africa No Time for Denial or Complacency 582Jerome Amir Singh Ross Upshur and Nesri Padayatchi

x contents

Part X Ethical Issues in the Practice of Healthcare 591

Introduction 593

Confidentiality 597

68 Confidentiality in Medicine A Decrepit Concept 599Mark Siegler

69 The Duty to Warn and Clinical Ethics Legal and Ethical Aspects of Confidentiality and HIVAIDS 603Christian Saumlfken and Andreas Frewer

Truth-Telling 611

70 On a Supposed Right to Lie from Altruistic Motives 613Immanuel Kant

71 Should Doctors Tell the Truth 615Joseph Collins

72 On Telling Patients the Truth 621Roger Higgs

Informed Consent and Patient Autonomy 629

73 On Liberty 631John Stuart Mill

74 From Schloendorff v NewYork Hospital 634Justice Benjamin N Cardozo

75 Informed Consent Its History Meaning and Present Challenges 635Tom L Beauchamp

76 The DoctorndashPatient Relationship in Different Cultures 642Ruth Macklin

77 Amputees by Choice 654Carl Elliott

78 Rational Desires and the Limitation of Life‐Sustaining Treatment 665Julian Savulescu

79 The Nocebo Effect of Informed Consent 683Shlomo Cohen

Part XI Special Issues Facing Nurses 693

Introduction 695

80 The Relation of the Nurse to the Doctor and the Doctor to the Nurse 699Sarah E Dock

81 In Defense of the Traditional Nurse 700Lisa H Newton

Contents xi

82 Patient Autonomy and Medical Paternity Can Nurses Help Doctors to Listen to Patients 708Sarah Breier

83 Health and Human Rights Advocacy Perspectives from a Rwandan Refugee Camp 718Carol Pavlish Anita Ho and Ann‐Marie Rounkle

Part XII Neuroethics 729

Introduction 731

84 Neuroethics An Agenda for Neuroscience and Society 733Jonathan D Moreno

85 How Electrical Brain Stimulation Can Change the Way We Think 741Sally Adee

86 Neuroethics Ethics and the Sciences of the Mind 744Neil Levy

87 Freedom of Memory Today 749Adam Kolber

88 Towards Responsible Use of Cognitive‐Enhancing Drugs by the Healthy 753Henry Greely Barbara Sahakian John Harris Ronald C Kessler Michael Gazzaniga Philip Campbell and Martha J Farah

89 Engineering Love 760Julian Savulescu and Anders Sandberg

Index 762

Acknowledgments

The editor and publisher gratefully acknowledge the permission granted to reproduce the copyright material in this book

1 John Finnis ldquoAbortion and Health Care Ethicsrdquo pp 547ndash57 from Raanan Gillon (ed) Principles of Health Care Ethics Chichester John Wiley 1994 Reproduced with permission from John Wiley amp Sons

2 Michael Tooley ldquoAbortion and Infanticiderdquo pp 37ndash65 from Philosophy and Public Affairs 1 (1972) Reproduced with permission from John Wiley amp Sons

3 Judith Jarvis Thomson ldquoA Defense of Abortionrdquo pp 47ndash66 from Philosophy and Public Affairs 1 1 (1971) Reproduced with permission from John Wiley amp Sons

4 Don Marquis ldquoWhy Abortion Is Immoralrdquo Journal of Philosophy 86 4 (April 1989) 183ndash202

5 Gregory Pence ldquoMultiple Gestation and Damaged Babies Godrsquos Will or Human Choicerdquo This essay draws on ldquoThe McCaughey Septuplets Godrsquos Will or Human Choicerdquo pp 39ndash43 from Gregory Pence Brave New Bioethics Lanham MD Rowman amp Littlefield 2002 copy Gregory Pence 2002 Courtesy of G Pence

6 Dorothy A Greenfeld and Emre Seli ldquoAssisted Reproduction in Same Sex Couplesrdquo pp 289ndash301 from M V Sauer (ed) Principles of Oocyte and Embryo Donation Springer‐Verlag 2013 With kind permisshysion from Springer Science+Business Media

7 Derek Parfit ldquoRights Interests and Possible Peoplerdquo pp 369ndash75 from Samuel Gorovitz et al (eds) Moral

Problems in Medicine Englewood Cliffs NJ Prentice Hall 1976 Courtesy of D Parfit

8 Ruby Catsanos Wendy Rogers and Mianna Lotz ldquoThe Ethics of Uterus Transplantationrdquo pp 65ndash73 from Bioethics 27 2 (2013) Reproduced by permission of John Wiley amp Sons

9 Laura M Purdy ldquoGenetics and Reproductive Risk Can Having Children be Immoralrdquo pp 39ndash49 from Reproducing Persons Issues in Feminist Bioethics Ithaca NY Cornell University Press 1996 Reproduced with permission from Cornell University Press

10 Adrienne Asch ldquoPrenatal Diagnosis and Selective Abortion A Challenge to Practice and Policyrdquo pp 1649ndash57 from American Journal of Public Health 89 11 (1999) Reproduced with permisshysion from American Public Health Association

11 Ruth Chadwick and Mairi Levitt ldquoGenetic Technology A Threat to Deafnessrdquo pp 209ndash15 from Medicine Healthcare and Philosophy 1 (1998) With kind permission from Springer Science+ Business Media

12 The Ethics Committee of the American Society of Reproductive Medicine ldquoSex Selection and Preimplantation Genetic Diagnosisrdquo pp 595ndash8 from Fertility and Sterility 72 4 (October 1999) Reprinted with permission from Elsevier

13 Julian Savulescu and Edgar Dahl ldquoSex Selection and Preimplantation Diagnosis A Response to the Ethics Committee of the American Society of Reproductive Medicinerdquo pp 1879ndash80 from Human Reproduction 15 9 (2000) By permission of Oxford University Press

Acknowledgments xiii

14 John A Robertson Jeffrey P Kahn and John E Wagner ldquoConception to Obtain Hematopoietic Stem Cellsrdquo pp 34ndash40 from Hastings Center Report 32 3 (MayJune 2002) Reproduced with permission from John Wiley amp Sons

15 David King ldquoWhy We Should Not Permit Embryos to Be Selected as Tissue Donorsrdquo pp 13ndash16 from The Bulletin of Medical Ethics 190 (August 2003) Copyright copy RSM Press 2003 Reproduced by permission of SAGE Publications Ltd London Los Angeles New Delhi Singapore and Washington DC

16 Michael Tooley ldquoThe Moral Status of the Cloning of Humansrdquo pp 67ndash101 from James M Humber and Robert I Almeder (eds) Human Cloning Totowa NJ Humana Press 1998 With kind permission from Springer Science+Business Media

17 Jonathan Glover ldquoQuestions about Some Uses of Genetic Engineeringrdquo pp 25ndash33 33ndash6 42ndash3 and 45ndash53 from What Sort of People Should There Be Harmondsworth Penguin Books 1984 Reproshyduced by permission of Penguin Books Ltd

18 David B Resnik ldquoThe Moral Significance of the TherapyndashEnhancement Distinction in Human Geneticsrdquo pp 365ndash77 from Cambridge Quarterly of Healthcare Ethics 9 3 (Summer 2000) copy Cambridge University Press Reproduced with permission

19 Ainsley Newson and Robert Williamson ldquoShould We Undertake Genetic Research on Intelligencerdquo pp 327ndash42 from Bioethics 13 34 (1999) Reproduced with permission from John Wiley amp Sons

20 Nick Bostrom ldquoIn Defense of Posthuman Dignityrdquo pp 202ndash14 from Bioethics 19 3 (2005) Reproduced with permission from John Wiley amp Sons

21 Jonathan Glover ldquoThe Sanctity of Liferdquo pp 39ndash59 from Causing Death and Lives London Pelican 1977 Reproduced by permission of Penguin Books Ltd

22 Sacred Congregation for the Doctrine of the Faith ldquoDeclaration on Euthanasiardquo Vatican City 1980

23 Germain Grisez and Joseph M Boyle Jr ldquoThe Morality of Killing A Traditional Viewrdquo

pp 381ndash419 from Life and Death with Liberty and Justice A Contribution to the Euthanasia Debate Notre Dame IN University of Notre Dame Press 1971

24 James Rachels ldquoActive and Passive Euthanasiardquo pp 78ndash80 from New England Journal of Medicine 292 (1975) Copyright copy 1975 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

25 Winston Nesbitt ldquoIs Killing No Worse Than Letting Dierdquo pp 101ndash5 from Journal of Applied Philosophy 12 1 (1995) Reproduced with permission from John Wiley amp Sons

26 Helga Kuhse ldquoWhy Killing Is Not Always Worse ndash and Sometimes Better ndash Than Letting Dierdquo pp 371ndash4 from Cambridge Quarterly of Healthcare 7 4 (1998) copy Cambridge University Press Reproduced with permission

27 Franklin G Miller Robert D Truog and Dan W Brock ldquoMoral Fictions and Medical Ethicsrdquo pp 453ndash60 from Bioethics 24 9 (2010) Reproduced with permission from John Wiley amp Sons

28 Neil Campbell ldquoWhen Care Cannot Cure Medical Problems in Seriously Ill Babiesrdquo pp 327ndash44 from F K Beller and R F Weir (eds) The Beginning of Human Life Dordrecht Kluwer Academic Publishers 1994 With kind pershymission from Springer Science+Business Media

29 R M Hare ldquoThe Abnormal Child Moral Dilemmas of Doctors and Parentsrdquo Reprinted in Essays on Bioethics Oxford Clarendon Press 1993 pp185ndash91 Courtesy of the Estate of R M Hare

30 Alison Davis ldquoRight to Life of Handicappedrdquo p 181 from Journal of Medical Ethics 9 (1983) Reproduced with permission from BMJ Publishing Group

31 Christine Overall ldquoConjoined Twins Embodied Personhood and Surgical Separationrdquo pp 69ndash84 from L Tessman (ed) Feminist Ethics and Social and Political Philosophy Theorizing the Non‐Ideal Springer 2009 With kind permission from Springer Science+Business Media

32 Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death ldquolsquoA Definition of Irreversible Comarsquo Report to Examine the Definition of Brain

xiv acknowledgments

Deathrdquo pp 85ndash8 from Journal of the American Medical Association 205 6 (August 1968) Copyright copy 1968 American Medical Association All rights reserved

33 Ari Joffe ldquoAre Recent Defences of the Brain Death Concept Adequaterdquo pp 47ndash53 from Bioethics 24 2 (February 2010) Reproduced with permission from John Wiley amp Sons

34 Peter Singer ldquoIs the Sanctity of Life Ethic Terminally Illrdquo pp 307ndash43 from Bioethics 9 34 (1995) Reproduced with permission from John Wiley amp Sons

35 Ronald Dworkin ldquoLife Past Reasonrdquo pp 218ndash29 from Lifersquos Dominion An Argument about Abortion Euthanasia and Individual Freedom New York Knopf 1993 Copyright copy 1993 by Ronald Dworkin Used by permission of Alfred A Knopf an imprint of the Knopf Doubleday Publishing Group a division of Random House LLC All rights reserved

36 Rebecca Dresser ldquoDworkin on Dementia Elegant Theory Questionable Policyrdquo pp 32ndash8 from Hastings Center Report 25 6 (NovemberDecember 1995) Reproduced with permission from John Wiley amp Sons

37 Chris Hill ldquoThe Noterdquo pp 9ndash17 from Helga Kuhse (ed) Willing to Listen Wanting to Die Ringwood Australia Penguin Books 1994

38 Daniel Callahan ldquoWhen Self‐Determination Runs Amokrdquo pp 52ndash5 from Hastings Center Report 22 2 (MarchApril 1992) Reproduced with permission from John Wiley amp Sons

39 John Lachs ldquoWhen Abstract Moralizing Runs Amokrdquo pp 10ndash13 from The Journal of Clinical Ethics 5 1 (Spring 1994) Copyright JCE

40 Bregje D Onwuteaka‐Philipsen et al ldquoTrends in End‐Of‐Life Practices Before and After the Enactment of the Euthanasia Law in the Netherlands from 1990 to 2010 A Repeated Cross‐Sectional Surveyrdquo pp 908ndash15 from The Lancet 380 9845 (2012) Reprinted from The Lancet with permission from Elsevier

41 Bernard Lo ldquoEuthanasia in the Netherlands What Lessons for Elsewhererdquo pp 869ndash70 from The Lancet 380 (September 8 2012) Copyright 2012 Reprinted from The Lancet with permisshysion from Elsevier

42 Paul T Menzel ldquoRescuing Lives Canrsquot We Countrdquo pp 22ndash3 from Hastings Center Report 24 1 (1994) Reproduced with permission from John Wiley amp Sons

43 Alvin H Moss and Mark Siegler ldquoShould Alcoholics Compete Equally for Liver Transshyplantationrdquo pp 1295ndash8 from Journal of the American Medical Association 265 10 (1991) Copyright copy 1991 American Medical Association All rights reserved

44 John Harris ldquoThe Value of Liferdquo pp 87ndash102 from The Value of Life London Routledge 1985 Copyright 1985 Routledge Reproduced by permission of Taylor amp Francis Books UK

45 Nick Beckstead and Toby Ord ldquoBubbles under the Wallpaper Healthcare Rationing and Disshycriminationrdquo a paper presented to the confershyence ldquoValuing Livesrdquo New York University March 5 2011 copy Nick Beckstead and Toby Ord reprinted by permission of the authors This paper is published here for the first time but draws on Nick Beckstead and Toby Ord ldquoRationing and Rationality The Cost of Avoiding Discriminationrdquo in N Eyal et al (eds) Inequalities in Health Concepts Measures and Ethics Oxford Oxford University Press 2013 pp 232ndash9 By permission of Oxford University Press

46 Eike‐Henner W Kluge ldquoOrgan Donation and Retrieval Whose Body Is It Anywayrdquo copy 1999 by Eike‐Henner W Kluge

47 Janet Radcliffe‐Richards et al ldquoThe Case for Allowing Kidney Salesrdquo pp 1950ndash2 from The Lancet 351 9120 (June 27 1998) Reprinted with permission from Elsevier

48 Debra Satz ldquoEthical Issues in the Supply and Demand of Human Kidneysrdquo pp 189ndash206 from Why Some Things Should Not Be for Sale The Moral Limits of Markets New York Oxford University Press 2010 ch 9 based on an article from Proceedings of the Aristotelian Society Reprinted by courtesy of the Editor of Proceedings of the Aristotelian Society copy 2010

49 John Harris ldquoThe Survival Lotteryrdquo pp 81ndash7 from Philosophy 50 (1975) copy Royal Institute of Philosophy published by Cambridge University Press Reproduced with permission

Acknowledgments xv

50 Henry K Beecher ldquoEthics and Clinical Researchrdquo pp 1354ndash60 from New England Journal of Medicine 274 24 (June 1966) Copyright copy 1996 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

51 Benjamin Freedman ldquoEquipoise and the Ethics of Clinical Researchrdquo pp 141ndash5 from New England Journal of Medicine 317 3 (July 1987) Copyright copy 1987 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

52 Samuel Hellman ldquoThe Patient and the Public Goodrdquo pp 400ndash2 from Nature Medicine 1 5 (1995) Reprinted by permission from Macmillan Publishers Ltd

53 John Harris ldquoScientific Research Is a Moral Dutyrdquo pp 242ndash8 from Journal of Medical Ethics 31 4 (2005) Reproduced with permission from BMJ Publishing Group

54 Sandra Shapshay and Kenneth D Pimple ldquoParticipation in Research Is an Imperfect Moral Duty A Response to John Harrisrdquo pp 414ndash17 from Journal of Medical Ethics 33 (2007) Reproduced with permission from BMJ Publishing Group

55 Peter Lurie and Sidney M Wolfe ldquoUnethical Trials of Interventions to Reduce Perinatal Transmission of the Human Immunodeficiency Virus in Developing Countriesrdquo pp 853ndash6 from New England Journal of Medicine 337 12 (September 1997) Copyright copy 1997 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

56 Danstan Bageda and Philippa Musoke‐Mudido ldquoWersquore Trying to Help Our Sickest People Not Exploit Themrdquo from The Washington Post September 28 1997 copy 1997 Washington Post Company All rights reserved Used by permisshysion and protected by the Copyright Laws of the United States The printing copying redistribushytion or retransmission of this Content without express written permission is prohibited

57 Leah Belsky and Henry S Richardson ldquoMedical Researchersrsquo Ancillary Clinical Care Respon sibilitiesrdquo pp 1494ndash6 from British

Medical Journal 328 (June 19 2004) Reproduced with permission from BMJ Publishing Group

58 George W Bush ldquoPresident Discusses Stem Cell Researchrdquo Office of the Press Secretary White House August 9 2001

59 Jeff McMahan ldquoKilling Embryos for Stem Cell Researchrdquo pp 170ndash89 from Metaphilosophy 38 23 (2007) Reproduced with permission from John Wiley amp Sons

60 Immanuel Kant ldquoDuties towards Animalsrdquo pp 239ndash41 from Lectures on Ethics trans Louis Infield London Methuen 1930 Copyright 1930 Methuen reproduced by permission of Taylor amp Francis Books UK

61 Jeremy Bentham ldquoA Utilitarian Viewrdquo section XVIII IV from An Introduction to the Principles of Morals and Legislation First published c1820

62 Peter Singer ldquoAll Animals are Equalrdquo pp 103ndash16 from Philosophic Exchange 1 5 (1974) Center for Philosophic Exchange State University of New York Brockford NY 1974

63 R G Frey and Sir William Paton ldquoVivisection Morals and Medicine An Exchangerdquo pp 94ndash7 and 102ndash4 from Journal of Medical Ethics 9 (1983) Reproduced with permission from BMJ Publishing Group

64 Michael J Selgelid ldquoEthics and Infectious Diseaserdquo pp 272ndash89 from Bioethics 19 3 (2005) Reproduced with permission from John Wiley amp Sons

65 Udo Schuumlklenk and Anita Kleinsmidt ldquoRethinking Mandatory HIV Testing during Pregnancy in Areas with High HIV Prevalence Rates Ethical and Policy Issuesrdquo pp 1179ndash83 from American Journal of Public Health 97 7 (2007) Reproduced with permission from American Public Health Association

66 Russell Armstrong ldquoMandatory HIV Testing in Pregnancy Is There Ever a Timerdquo pp 1ndash10 from Developing World Bioethics 8 1 (2008) Reproduced with permission from John Wiley amp Sons

67 Jerome Amir Singh Ross Upshur and Nesri Padayatchi ldquoXDR‐TB in South Africa No Time for Denial or Complacencyrdquo PLoS Med 4 1 (2007) e50 doi101371journalpmed0040050 Copyright copy 2007 Singh et al

xvi acknowledgments

68 Mark Siegler ldquoConfidentiality in Medicine A Decrepit Conceptrdquo pp 1518ndash21 from New England Journal of Medicine 307 24 (December 1982) Copyright copy 1982 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

69 Christian Saumlfken and Andreas Frewer ldquoThe Duty to Warn and Clinical Ethics Legal and Ethical Aspects of Confidentiality and HIVAIDSrdquo pp 313ndash326 from HEC Forum 19 4 (2007) With kind permission from Springer Science+Business Media

70 Immanuel Kant ldquoOn a Supposed Right to Lie from Altruistic Motivesrdquo pp 361ndash3 from Critique of Practical Reason and Other Works on the Theory of Ethics 6th edition trans T K Abbott London 1909 This essay was first published in a Berlin periodical in 1797

71 Joseph Collins ldquoShould Doctors Tell the Truthrdquo pp 320ndash6 from Harperrsquos Monthly Magazine 155 (August 1927) Copyright copy 1927 Harperrsquos Magazine All rights reserved Reproduced from the August issue by special permission

72 Roger Higgs ldquoOn Telling Patients the Truthrdquo pp 186ndash202 and 232ndash3 from Michael Lockwood (ed) Moral Dilemmas in Modern Medicine Oxford Oxford University Press 1985 By permission of Oxford University Press

73 John Stuart Mill ldquoOn Libertyrdquo first published in 1859

74 Justice Benjamin N Cardozo Judgment from Schloendorff v New York Hospital (1914) p 526 from Jay Katz (ed) Experimentation with Human Beings The Authority of the Investigator Subject Professions and State in the Human Experimentation Process New York Russell Sage Foundation 1972 Reproduced with permission of Russell Sage Foundation

75 Tom L Beauchamp ldquoInformed Consent Its History Meaning and Present Challengesrdquo pp 515ndash23 from Cambridge Quarterly of Health Care Ethics 20 4 (2011) copy Royal Institute of Philosophy published by Cambridge University Press Reproduced with permission from Cambridge University Press and T Beauchamp

76 Ruth Macklin ldquoThe DoctorndashPatient Relationshyship in Different Culturesrdquo pp 86ndash107 from

Against Relativism Cultural Diversity and the Search of Ethical Universals in Medicine copy 1999 by Oxford University Press Inc By permission of Oxford University Press USA

77 Carl Elliott ldquoAmputees by Choicerdquo pp 208ndash10 210ndash15 219ndash23 227ndash31 234ndash6 323ndash6 from Better Than Well American Medicine Meets the American Dream New York and London WW Norton 2003 Copyright copy 2003 by Carl Elliott Used by permission of W W Norton amp Company Inc

78 Julian Savulescu ldquoRational Desires and the Limishytation of Life‐Sustaining Treatmentrdquo pp 191ndash 222 from Bioethics 8 3 (1994) Reproduced with permission from John Wiley amp Sons

79 Shlomo Cohen ldquoThe Nocebo Effect of Informed Consentrdquo pp 147ndash54 from Bioethics 28 3 (2014) Reproduced with permission from John Wiley amp Sons

80 Sarah E Dock ldquoThe Relation of the Nurse to the Doctor and the Doctor to the Nurserdquo p 394 (extract) from The American Journal of Nursing 17 5 (1917)

81 Lisa H Newton ldquoIn Defense of the Traditional Nurserdquo pp 348ndash54 from Nursing Outlook 29 6 (1981) Copyright Elsevier 1981

82 Sarah Breier ldquoPatient Autonomy and Medical Paternity Can Nurses Help Doctors to Listen to Patientsrdquo pp 510ndash21 from Nursing Ethics 8 6 (2001) Reproduced with permission from Sage and S Breier

83 Carol Pavlish Anita Ho and Ann‐Marie Rounkle ldquoHealth and Human Rights Advocacy Perspectives from a Rwandan Refugee Camprdquo pp 538ndash49 from Nursing Ethics 19 4 (2012) Copyright copy 2012 by SAGE Publications Reprinted by Permission of SAGE

84 Jonathan D Moreno ldquoNeuroethics An Agenda for Neuroscience and Societyrdquo pp 149ndash53 from Nature Reviews 4 (February 2003)Reprinted by permission from Macmillan Publishers Ltd

85 Sally Adee ldquoHow Electrical Brain Stimulation Can Change the Way We Thinkrdquo The Week March 30 2012

86 Neil Levy ldquoNeuroethics Ethics and the Sciences of the Mindrdquo pp 69ndash74 (extract) from Philosophy

Acknowledgments xvii

Compass 4 10 (2009) pp 69ndash81 Reproduced with permission from John Wiley amp Sons

87 Adam Kolber ldquoFreedom of Memory Todayrdquo pp 145ndash8 from Neuroethics 1 (2008) With kind permission from Springer Science+Business Media

88 Henry Greely and Colleagues ldquoTowards Responsible Use of Cognitive‐Enhancing Drugs

by the Healthyrdquo pp 702ndash5 from Nature 456 (December 11 2008) Reprinted by permission from Macmillan Publishers Ltd

89 Julian Savulescu and Anders Sandberg ldquoEngineering LoverdquoldquoLove Machine Engineering Lifelong Romancerdquo pp 28ndash9 from New Scientist 2864 copy 2012 Reed Business Information ndash UK All rights reserved Distributed by Tribune Content Agency

Bioethics An Anthology Third Edition Edited by Helga Kuhse Udo Schuumlklenk and Peter Singer copy 2016 John Wiley amp Sons Inc Published 2016 by John Wiley amp Sons Inc

Introduction

The term ldquobioethicsrdquo was coined by Van Rensselaer Potter who used it to describe his proposal that we need an ethic that can incorporate our obligations not just to other humans but to the biosphere as a whole1 Although the term is still occasionally used in this sense of an ecological ethic it is now much more commonly used in the narrower sense of the study of ethical issues arising from the biological and medical sciences So understood bioethics has become a specialized although interdisciplinary area of study The essays included in this book give an indication of the range of issues which fall within its scope ndash but it is only an indication There are many other issues that we simply have not had the space to cover

Bioethics can be seen as a branch of ethics or more specifically of applied ethics For this reason some understanding of the nature of ethics is an essential preliminary to any serious study of bioethics The remainder of this introduction will seek to provide that understanding

One question about the nature of ethics is especially relevant to bioethics to what extent is reasoning or argument possible in ethics Many people assume without much thought that ethics is subjective The subjectivist holds that what ethical view we take is a matter of opinion or taste that is not amenable to argument But if ethics were a matter of taste why would we even attempt to argue about it If Helen says ldquoI like my coffee sweetenedrdquo whereas Paul says

ldquoI like my coffee unsweetenedrdquo there is not much point in Helen and Paul arguing about it The two statements do not contradict each other They can both be true But if Helen says ldquoDoctors should never assist their patients to dierdquo whereas Paul says ldquoSometimes doctors should assist their patients to dierdquo then Helen and Paul are disagreeing and there does seem to be a point in their trying to argue about the issue of physician‐assisted suicide

It seems clear that there is some scope for argument in ethics If I say ldquoIt is always wrong to kill a human beingrdquo and ldquoAbortion is not always wrongrdquo then I am committed to denying that abortion kills a human being Otherwise I have contradicted myself and in doing so I have not stated a coherent position at all So consistency at least is a requirement of any defensible ethical position and thus sets a limit to the subjectivity of ethical judgments The requirement of factual accuracy sets another limit In discussing issues in bioethics the facts are often complex But we cannot reach the right ethical decisions unless we are well‐informed about the relevant facts In this respect ethical decisions are unlike decisions of taste We can enjoy a taste without knowing what we are eating but if we assume that it is wrong to resuscitate a terminally ill patient against her wishes then we can-not know whether an instance of resuscitation was morally right or wrong without knowing something about the patientrsquos prognosis and whether the patient

2 introduction

has expressed any wishes about being resuscitated In that sense there is no equivalent in ethics to the immediacy of taste

Ethical relativism sometimes also known as cul-tural relativism is one step away from ethical sub-jectivism but it also severely limits the scope of ethical argument The ethical relativist holds that it is not individual attitudes that determine what is right or wrong but the attitudes of the culture in which one lives Herodotus tells how Darius King of Persia summoned the Greeks from the western shores of his kingdom before him and asked them how much he would have to pay them to eat their fathersrsquo dead bodies They were horrified by the idea and said they would not do it for any amount of money for it was their custom to cremate their dead Then Darius called upon Indians from the eastern frontiers of his kingdom and asked them what would make them willing to burn their fathersrsquo bodies They cried out and asked the King to refrain from mentioning so shocking an act Herodotus comments that each nation thinks its own customs best From here it is only a short step to the view that there can be no objective right or wrong beyond the bounds of onersquos own culture This view found increased support in the nine-teenth century as Western anthropologists came to know many different cultures and were impressed by ethical views very different from those that were standardly taken for granted in European society As a defense against the automatic assumption that Western morality is superior and should be imposed on ldquosavagesrdquo many anthropologists argued that since morality is relative to culture no culture can have any basis for regarding its morality as superior to any other culture

Although the motives with which anthropolo-gists put this view forward were admirable they may not have appreciated the implications of the position they were taking The ethical relativist maintains that a statement like ldquoIt is good to enslave people from another tribe if they are captured in warrdquo means simply ldquoIn my society the custom is to enslave people from another tribe if they are cap-tured in warrdquo Hence if one member of the society were to question whether it really was good to enslave people in these circumstances she could be

answered simply by demonstrating that this was indeed the custom ndash for example by showing that for many generations it had been done after every war in which prisoners were captured Thus there is no way for moral reformers to say that an accepted custom is wrong ndash ldquowrongrdquo just means ldquoin accord-ance with an accepted customrdquo

On the other hand when people from two different cultures disagree about an ethical issue then according to the ethical relativist there can be no resolution of the disagreement Indeed strictly there is no disagree-ment If the apparent dispute were over the issue just mentioned then one person would be saying ldquoIn my country it is the custom to enslave people from another tribe if they are captured in warrdquo and the other person would be saying ldquoIn my country it is not the custom to allow one human being to enslave anotherrdquo This is no more a disagreement than such statements as ldquoIn my country people greet each other by rubbing nosesrdquo and ldquoIn my country people greet each other by shaking handsrdquo If ethical relativism is true then it is impossible to say that one culture is right and the other is wrong Bearing in mind that some cultures have practiced slavery or the burning of widows on the funeral pyre of their husbands this is hard to accept

A more promising alternative to both ethical subjectivism and cultural relativism is universal pre-scriptivism an approach to ethics developed by the Oxford philosopher R M Hare Hare argues that the distinctive property of ethical judgments is that they are universalizable In saying this he means that if I make an ethical judgment I must be prepared to state it in universal terms and apply it to all relevantly similar situations By ldquouniversal termsrdquo Hare means those terms that do not refer to a particular individual Thus a proper name cannot be a universal term If for example I were to say ldquoEveryone should do what is in the interests of Mick Jaggerrdquo I would not be making a universal judgment because I have used a proper name The same would be true if I were to say that everyone must do what is in my interests because the personal pronoun ldquomyrdquo is here used to refer to a particular individual myself

It might seem that ruling out particular terms in this way does not take us very far After all one can always describe oneself in universal terms Perhaps

Introduction 3

I canrsquot say that everyone should do what is in my interests but I could say that everyone must do whatever is in the interests of people who hellip and then give a minutely detailed description of myself including the precise location of all my freckles The effect would be the same as saying that everyone should do what is in my interests because there would be no one except me who matches that description But Hare meets this problem very effectively by saying that to prescribe an ethical judgment universally means being prepared to pre-scribe it for all possible circumstances including hypothetical ones So if I were to say that everyone should do what is in the interests of a person with a particular pattern of freckles I must be prepared to prescribe that in the hypothetical situation in which I do not have this pattern of freckles but someone else does I should do what is in the interests of that person Now of course I may say that I should do that since I am confident that I shall never be in such a situation but this simply means that I am being dishonest I am not genuinely prescribing the principle universally

The effect of saying that an ethical judgment must be universalizable for hypothetical as well as actual circumstances is that whenever I make an ethical judgment I can be challenged to put myself in the position of the parties affected and see if I would still be able to accept that judgment Suppose for example that I own a small factory and the cheapest way for me to get rid of some waste is to pour it into a nearby river I do not take water from this river but I know that some villagers living downstream do and the waste may make them ill The requirement that ethical judgments should be universalizable will make it difficult for me to justify my conduct because if I imagine myself in the hypothetical situation of being one of the villagers rather than the factory‐owner I would not accept that the profits of the factory‐owner should outweigh the risk of adverse effects on my health and that of my children In this way Harersquos approach requires us to take into account the interests and preferences of all others affected by our actions Hence it allows for an element of reasoning in ethical deliberation

Since the rightness or wrongness of our actions will on this view depend on the way in which they

affect others Harersquos universal prescriptivism leads to a form of consequentialism ndash that is the view that the rightness of an action depends on its consequences The best‐known form of consequentialism is the clas-sical utilitarianism developed in the late eighteenth century by Jeremy Bentham and popularized in the nineteenth century by John Stuart Mill They held that an action is right if it leads to a greater surplus of happiness over misery than any possible alternative and wrong if it does not By ldquogreater surplus of happinessrdquo the classical utilitarians had in mind the idea of adding up all the pleasure or happiness that resulted from the action and subtracting from that total all the pain or misery to which the action gave rise Naturally in some circumstances it might be possible only to reduce misery and then the right action should be understood as the one that will result in less misery than any possible alternative

The utilitarian view is striking in many ways It puts forward a single principle that it claims can provide the right answer to all ethical dilemmas if only we can predict what the consequences of our actions will be It takes ethics out of the mysterious realm of duties and rules and bases ethical decisions on something that almost everyone understands and values Moreover utilitarianismrsquos single principle is applied universally without fear or favor Bentham said ldquoEach to count for one and none for more than onerdquo by which he meant that the happiness of a com-mon tramp counted for as much as that of a noble and the happiness of an African was no less important than that of a European

Many contemporary consequentialists agree with Bentham to the extent that they think the rightness or wrongness of an action must depend on its conse-quences but they have abandoned the idea that m aximizing net happiness is the ultimate goal Instead they argue that we should seek to bring about w hatever will satisfy the greatest number of desires or preference This variation which is known as ldquop reference utilitarianismrdquo does not regard anything as good except in so far as it is wanted or desired More intense or strongly held preferences would get more weight than weak preferences

Consequentialism offers one important answer to the question of how we should decide what is right and what is wrong but many ethicists reject it The

4 introduction

denial of this view was dramatically presented by Dostoevsky in The Karamazov Brothers

imagine that you are charged with building the edifice of human destiny the ultimate aim of which is to bring people happiness to give them peace and contentment at last but that in order to achieve this it is essential and unavoidable to torture just one little speck of creation that same little child beating her chest with her little fists and imagine that this edifice has to be erected on her unexpiated tears Would you agree to be the architect under those conditions Tell me honestly2

The passage suggests that some things are always wrong no matter what their consequences This has for most of Western history been the prevailing approach to morality at least at the level of what has been officially taught and approved by the institutions of Church and State The ten commandments of the Hebrew scriptures served as a model for much of the Christian era and the Roman Catholic Church built up an elaborate system of morality based on rules to which no exceptions were allowed

Another example of an ethic of rules is that of Immanuel Kant Kantrsquos ethic is based on his ldquocategori-cal imperativerdquo which he states in several distinct for-mulations One is that we must always act so that we can will the maxim of our action to be a universal law This can be interpreted as a form of Harersquos idea of universalizability which we have already encountered Another is that we must always treat other people as ends never as means While these formulations of the categorical imperative might be applied in various ways in Kantrsquos hands they lead to inviolable rules for example against making promises that we do not intend to keep Kant also thought that it was always wrong to tell a lie In response to a critic who sug-gested that this rule has exceptions Kant said that it would be wrong to lie even if someone had taken refuge in your house and a person seeking to murder him came to your door and asked if you knew where he was Modern Kantians often reject this hard-line approach to rules and claim that Kantrsquos categorical imperative did not require him to hold so strictly to the rule against lying

How would a consequentialist ndash for example a classical utilitarian ndash answer Dostoevskyrsquos challenge If answering honestly ndash and if one really could be certain

that this was a sure way and the only way of bringing lasting happiness to all the people of the world ndash utilitarians would have to say yes they would accept the task of being the architect of the happiness of the world at the cost of the childrsquos unexpiated tears For they would point out that the suffering of that child wholly undeserved as it is will be repeated a million‐fold over the next century for other children just as innocent who are victims of starvation disease and brutality So if this one child must be sacrificed to stop all this suffering then terrible as it is the child must be sacrificed

Fantasy apart there can be no architect of the hap-piness of the world The world is too big and complex a place for that But we may attempt to bring about less suffering and more happiness or satisfaction of preferences for people or sentient beings in specific places and circumstances Alternatively we might fol-low a set of principles or rules ndash which could be of varying degrees of rigidity or flexibility Where would such rules come from Kant tried to deduce them from his categorical imperative which in turn he had reached by insisting that the moral law must be based on reason alone without any content from our wants or desires But the problem with trying to deduce morality from reason alone has always been that it becomes an empty formalism that cannot tell us what to do To make it practical it needs to have some addi-tional content and Kantrsquos own attempts to deduce rules of conduct from his categorical imperative are unconvincing

Others following Aristotle have tried to draw on human nature as a source of moral rules What is good they say is what is natural to human beings They then contend that it is natural and right for us to seek certain goods such as knowledge friendship health love and procreation and unnatural and wrong for us to act contrary to these goods This ldquonatural lawrdquo ethic is open to criticism on several points The word ldquonaturalrdquo can be used both descriptively and evalua-tively and the two senses are often mixed together so that value judgments may be smuggled in under the guise of a description The picture of human nature presented by proponents of natural law ethics usually selects only those characteristics of our nature that the proponent considers desirable The fact that our species especially its male members frequently go to war and

Introduction 5

are also prone to commit individual acts of violence against others is no doubt just as much part of our nature as our desire for knowledge but no natural law theorist therefore views these activities as good More generally natural law theory has its origins in an Aristotelian idea of the cosmos in which everything has a goal or ldquoendrdquo which can be deduced from its nature The ldquoendrdquo of a knife is to cut the assumption is that human beings also have an ldquoendrdquo and we will flourish when we live in accordance with the end for which we are suited But this is a pre‐Darwinian view of nature Since Darwin we know that we do not exist for any purpose but are the result of natural selection operating on random mutations over millions of years Hence there is no reason to believe that living accord-ing to nature will produce a harmonious society let alone the best possible state of affairs for human beings

Another way in which it has been claimed that we can come to know what moral principles or rules we should follow is through our intuition In practice this usually means that we adopt conven-tionally accepted moral principles or rules perhaps with some adjustments in order to avoid inconsist-ency or arbitrariness On this view a moral theory should like a scientific theory try to match the data and the data that a moral theory must match is p rovided by our moral intuitions As in science if a plausible theory matches most but not all of the data then the anomalous data might be rejected on the grounds that it is more likely that there was an error in the procedures for gathering that particular set of data than that the theory as a whole is mis-taken But ultimately the test of a theory is its ability to explain the data The problem with applying this model of scientific justification to ethics is that the ldquodatardquo of our moral intuitions is unreliable not just at one or two specific points but as a whole Here the facts that cultural relativists draw upon are rele-vant (even if they do not establish that cultural rela-tivism is the correct response to it) Since we know that our intuitions are strongly influenced by such things as culture and religion they are ill‐suited to serve as the fixed points against which an ethical theory must be tested Even where there is cross‐cultural agreement there may be some aspects of our intuitions on which all cultures unjustifiably favor our own interests over those of others For

example simply because we are all human beings we may have a systematic bias that leads us to give an unjustifiably low moral status to nonhuman a nimals Or because in virtually all known human societies men have taken a greater leadership role than women the moral intuitions of all societies may not adequately reflect the interests of females

Some philosophers think that it is a mistake to base ethics on principles or rules Instead they focus on what it is to be a good person ndash or in the case of the problems with which this book is concerned perhaps on what it is to be a good nurse or doctor or researcher They seek to describe the virtues that a good person or a good member of the relevant profession should possess Moral education then consists of teaching these virtues and discussing how a virtuous person would act in specific situations The question is how-ever whether we can have a notion of what a virtuous person would do in a specific situation without making a prior decision about what it is right to do After all in any particular moral dilemma different virtues may be applicable and even a particular virtue will not always give unequivocal guidance For instance if a terminally ill patient repeatedly asks a nurse or doctor for assistance in dying what response best exemplifies the virtues of a healthcare professional There seems no answer to this question short of an inquiry into whether it is right or wrong to help a patient in such circumstances to die But in that case we seem bound in the end to come back to discuss-ing such issues as whether it is right to follow moral rules or principles or to do what will have the best consequences

In the late twentieth century some feminists offered new criticisms of conventional thought about ethics They argued that the approaches to ethics taken by the influential philosophers of the past ndash all of whom have been male ndash give too much emphasis to abstract principles and the role of reason and give too little attention to personal relationships and the part played by emotion One outcome of these criticisms has been the development of an ldquoethic of carerdquo which is not so much a single ethical theory as a cluster of ways of looking at ethics which put an attitude of c aring for others at the center and seek to avoid r eliance on abstract ethical principles The ethic of care has seemed especially applicable to the work of those

6 introduction

involved in direct patient care and has recently been taken up by a number of nursing theorists as offering a more suitable alternative to other ideas of ethics Not all feminists however support this development Some worry that the adoption of a ldquocarerdquo approach by nurses may reflect and even reinforce stereotypes of women as more emotional and less rational than men They also fear that it could lead to women continuing to carry a disproportionate burden of caring for others to the exclusion of adequately caring for themselves

In this discussion of ethics we have not mentioned anything about religion This may seem odd in view of the close connection that has often been made between religion and ethics but it reflects our belief that despite this historical connection ethics and reli-gion are fundamentally independent Logically ethics is prior to religion If religious believers wish to say that a deity is good or praise her or his creation or deeds they must have a notion of goodness that is independent of their conception of the deity and what she or he does Otherwise they will be saying that the deity is good and when asked what they mean by ldquogoodrdquo they will have to refer back to the deity saying perhaps that ldquogoodrdquo means ldquoin accord-ance with the wishes of the deityrdquo In that case sen-tences such as ldquoGod is goodrdquo would be a meaningless tautology ldquoGod is goodrdquo could mean no more than ldquoGod is in accordance with Godrsquos wishesrdquo As we have already seen there are ideas of what it is for something to be ldquogoodrdquo that are not rooted in any religious belief While religions typically encourage or instruct their followers to obey a particular ethical code it is obvious that others who do not follow any religion can also think and act ethically

To say that ethics is independent of religion is not to deny that theologians or other religious believers may have a role to play in bioethics Religious traditions often have long histories of dealing with ethical dilem-mas and the accumulation of wisdom and experience that they represent can give us valuable insights into particular problems But these insights should be subject to criticism in the way that any other proposals would be If in the end we accept them it is because we have judged them sound not because they are the utterances of a pope a rabbi a mullah or a holy person

Ethics is also independent of the law in the sense that the rightness or wrongness of an act cannot be

settled by its legality or illegality Whether an act is legal or illegal may often be relevant to whether it is right or wrong because it is arguably wrong to break the law other things being equal Many people have thought that this is especially so in a democracy in which everyone has a say in making the law Another reason why the fact that an act is illegal may be a rea-son against doing it is that the legality of an act may affect the consequences that are likely to flow from it If active voluntary euthanasia is illegal then doctors who practice it risk going to jail which will cause them and their families to suffer and also mean that they will no longer be able to help other patients This can be a powerful reason for not practicing voluntary euthanasia when it is against the law but if there is only a very small chance of the offense becoming known or being proved then the weight of this con-sequentialist reason against breaking the law is reduced accordingly Whether we have an ethical obligation to obey the law and if so how much weight should be given to it is itself an issue for ethical argument

Though ethics is independent of the law in the sense just specified laws are subject to evaluation from an ethical perspective Many debates in bioethics focus on questions about what practices should be allowed ndash for example should we allow research on stem cells taken from human embryos sex selection or cloning ndash and committees set up to advise on the ethical social and legal aspects of these questions often recommend legislation to prohibit the activity in question or to allow it to be practiced under some form of regulation Discussing a question at the level of law and public policy however raises somewhat different considerations than a discussion of personal ethics because the consequences of adopting a public policy generally have much wider ramifications than the consequences of a personal choice That is why some healthcare professionals feel justified in assisting a terminally ill patient to die while at the same time opposing the legalization of physician‐assisted suicide Paradoxical as this position may appear ndash and it is certainly open to criticism ndash it is not straightforwardly inconsistent

Naturally many of the essays we have selected reflect the times in which they were written Since bioethics often comments on developments in fast‐moving

Introduction 7

areas of medicine and the biological sciences the factual content of articles in bioethics can become obsolete quite rapidly In preparing this revised edition we have taken the opportunity to cover some new issues and to include some more recent writings We have for example included new mate-rial on genetic enhancement as well as on the use of embryonic human stem cells This edition of the anthology also includes new sections on ethical issues in public health and in the neurosciences Nevertheless an article that has dated in regard to its facts often makes ethical points that are still valid

or worth considering so we have not excluded older articles for this reason

Other articles are dated in a different way During the past few decades we have become more sensitive about the ways in which our language may exclude women or reflect our prejudices regarding race or sexuality We see no merit in trying to disguise past practices on such matters so we have not excluded otherwise valuable works in bioethics on these grounds If they are jar-ring to the modern reader that may be a salutary reminder of the extent to which we all are subject to the conventions and prejudices of our times

Notes

1 See Van Rensselaer Potter Bioethics Bridge to the Future (Englewood Cliffs NJ Prentice‐Hall 1971)

2 The Karamazov Brothers trans Ignat Avsey (Oxford Oxford University Press 1994) vol I part 2 bk 5 ch 4 First published in 1879

Abortion

Part I

x contents

Part X Ethical Issues in the Practice of Healthcare 591

Introduction 593

Confidentiality 597

68 Confidentiality in Medicine A Decrepit Concept 599Mark Siegler

69 The Duty to Warn and Clinical Ethics Legal and Ethical Aspects of Confidentiality and HIVAIDS 603Christian Saumlfken and Andreas Frewer

Truth-Telling 611

70 On a Supposed Right to Lie from Altruistic Motives 613Immanuel Kant

71 Should Doctors Tell the Truth 615Joseph Collins

72 On Telling Patients the Truth 621Roger Higgs

Informed Consent and Patient Autonomy 629

73 On Liberty 631John Stuart Mill

74 From Schloendorff v NewYork Hospital 634Justice Benjamin N Cardozo

75 Informed Consent Its History Meaning and Present Challenges 635Tom L Beauchamp

76 The DoctorndashPatient Relationship in Different Cultures 642Ruth Macklin

77 Amputees by Choice 654Carl Elliott

78 Rational Desires and the Limitation of Life‐Sustaining Treatment 665Julian Savulescu

79 The Nocebo Effect of Informed Consent 683Shlomo Cohen

Part XI Special Issues Facing Nurses 693

Introduction 695

80 The Relation of the Nurse to the Doctor and the Doctor to the Nurse 699Sarah E Dock

81 In Defense of the Traditional Nurse 700Lisa H Newton

Contents xi

82 Patient Autonomy and Medical Paternity Can Nurses Help Doctors to Listen to Patients 708Sarah Breier

83 Health and Human Rights Advocacy Perspectives from a Rwandan Refugee Camp 718Carol Pavlish Anita Ho and Ann‐Marie Rounkle

Part XII Neuroethics 729

Introduction 731

84 Neuroethics An Agenda for Neuroscience and Society 733Jonathan D Moreno

85 How Electrical Brain Stimulation Can Change the Way We Think 741Sally Adee

86 Neuroethics Ethics and the Sciences of the Mind 744Neil Levy

87 Freedom of Memory Today 749Adam Kolber

88 Towards Responsible Use of Cognitive‐Enhancing Drugs by the Healthy 753Henry Greely Barbara Sahakian John Harris Ronald C Kessler Michael Gazzaniga Philip Campbell and Martha J Farah

89 Engineering Love 760Julian Savulescu and Anders Sandberg

Index 762

Acknowledgments

The editor and publisher gratefully acknowledge the permission granted to reproduce the copyright material in this book

1 John Finnis ldquoAbortion and Health Care Ethicsrdquo pp 547ndash57 from Raanan Gillon (ed) Principles of Health Care Ethics Chichester John Wiley 1994 Reproduced with permission from John Wiley amp Sons

2 Michael Tooley ldquoAbortion and Infanticiderdquo pp 37ndash65 from Philosophy and Public Affairs 1 (1972) Reproduced with permission from John Wiley amp Sons

3 Judith Jarvis Thomson ldquoA Defense of Abortionrdquo pp 47ndash66 from Philosophy and Public Affairs 1 1 (1971) Reproduced with permission from John Wiley amp Sons

4 Don Marquis ldquoWhy Abortion Is Immoralrdquo Journal of Philosophy 86 4 (April 1989) 183ndash202

5 Gregory Pence ldquoMultiple Gestation and Damaged Babies Godrsquos Will or Human Choicerdquo This essay draws on ldquoThe McCaughey Septuplets Godrsquos Will or Human Choicerdquo pp 39ndash43 from Gregory Pence Brave New Bioethics Lanham MD Rowman amp Littlefield 2002 copy Gregory Pence 2002 Courtesy of G Pence

6 Dorothy A Greenfeld and Emre Seli ldquoAssisted Reproduction in Same Sex Couplesrdquo pp 289ndash301 from M V Sauer (ed) Principles of Oocyte and Embryo Donation Springer‐Verlag 2013 With kind permisshysion from Springer Science+Business Media

7 Derek Parfit ldquoRights Interests and Possible Peoplerdquo pp 369ndash75 from Samuel Gorovitz et al (eds) Moral

Problems in Medicine Englewood Cliffs NJ Prentice Hall 1976 Courtesy of D Parfit

8 Ruby Catsanos Wendy Rogers and Mianna Lotz ldquoThe Ethics of Uterus Transplantationrdquo pp 65ndash73 from Bioethics 27 2 (2013) Reproduced by permission of John Wiley amp Sons

9 Laura M Purdy ldquoGenetics and Reproductive Risk Can Having Children be Immoralrdquo pp 39ndash49 from Reproducing Persons Issues in Feminist Bioethics Ithaca NY Cornell University Press 1996 Reproduced with permission from Cornell University Press

10 Adrienne Asch ldquoPrenatal Diagnosis and Selective Abortion A Challenge to Practice and Policyrdquo pp 1649ndash57 from American Journal of Public Health 89 11 (1999) Reproduced with permisshysion from American Public Health Association

11 Ruth Chadwick and Mairi Levitt ldquoGenetic Technology A Threat to Deafnessrdquo pp 209ndash15 from Medicine Healthcare and Philosophy 1 (1998) With kind permission from Springer Science+ Business Media

12 The Ethics Committee of the American Society of Reproductive Medicine ldquoSex Selection and Preimplantation Genetic Diagnosisrdquo pp 595ndash8 from Fertility and Sterility 72 4 (October 1999) Reprinted with permission from Elsevier

13 Julian Savulescu and Edgar Dahl ldquoSex Selection and Preimplantation Diagnosis A Response to the Ethics Committee of the American Society of Reproductive Medicinerdquo pp 1879ndash80 from Human Reproduction 15 9 (2000) By permission of Oxford University Press

Acknowledgments xiii

14 John A Robertson Jeffrey P Kahn and John E Wagner ldquoConception to Obtain Hematopoietic Stem Cellsrdquo pp 34ndash40 from Hastings Center Report 32 3 (MayJune 2002) Reproduced with permission from John Wiley amp Sons

15 David King ldquoWhy We Should Not Permit Embryos to Be Selected as Tissue Donorsrdquo pp 13ndash16 from The Bulletin of Medical Ethics 190 (August 2003) Copyright copy RSM Press 2003 Reproduced by permission of SAGE Publications Ltd London Los Angeles New Delhi Singapore and Washington DC

16 Michael Tooley ldquoThe Moral Status of the Cloning of Humansrdquo pp 67ndash101 from James M Humber and Robert I Almeder (eds) Human Cloning Totowa NJ Humana Press 1998 With kind permission from Springer Science+Business Media

17 Jonathan Glover ldquoQuestions about Some Uses of Genetic Engineeringrdquo pp 25ndash33 33ndash6 42ndash3 and 45ndash53 from What Sort of People Should There Be Harmondsworth Penguin Books 1984 Reproshyduced by permission of Penguin Books Ltd

18 David B Resnik ldquoThe Moral Significance of the TherapyndashEnhancement Distinction in Human Geneticsrdquo pp 365ndash77 from Cambridge Quarterly of Healthcare Ethics 9 3 (Summer 2000) copy Cambridge University Press Reproduced with permission

19 Ainsley Newson and Robert Williamson ldquoShould We Undertake Genetic Research on Intelligencerdquo pp 327ndash42 from Bioethics 13 34 (1999) Reproduced with permission from John Wiley amp Sons

20 Nick Bostrom ldquoIn Defense of Posthuman Dignityrdquo pp 202ndash14 from Bioethics 19 3 (2005) Reproduced with permission from John Wiley amp Sons

21 Jonathan Glover ldquoThe Sanctity of Liferdquo pp 39ndash59 from Causing Death and Lives London Pelican 1977 Reproduced by permission of Penguin Books Ltd

22 Sacred Congregation for the Doctrine of the Faith ldquoDeclaration on Euthanasiardquo Vatican City 1980

23 Germain Grisez and Joseph M Boyle Jr ldquoThe Morality of Killing A Traditional Viewrdquo

pp 381ndash419 from Life and Death with Liberty and Justice A Contribution to the Euthanasia Debate Notre Dame IN University of Notre Dame Press 1971

24 James Rachels ldquoActive and Passive Euthanasiardquo pp 78ndash80 from New England Journal of Medicine 292 (1975) Copyright copy 1975 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

25 Winston Nesbitt ldquoIs Killing No Worse Than Letting Dierdquo pp 101ndash5 from Journal of Applied Philosophy 12 1 (1995) Reproduced with permission from John Wiley amp Sons

26 Helga Kuhse ldquoWhy Killing Is Not Always Worse ndash and Sometimes Better ndash Than Letting Dierdquo pp 371ndash4 from Cambridge Quarterly of Healthcare 7 4 (1998) copy Cambridge University Press Reproduced with permission

27 Franklin G Miller Robert D Truog and Dan W Brock ldquoMoral Fictions and Medical Ethicsrdquo pp 453ndash60 from Bioethics 24 9 (2010) Reproduced with permission from John Wiley amp Sons

28 Neil Campbell ldquoWhen Care Cannot Cure Medical Problems in Seriously Ill Babiesrdquo pp 327ndash44 from F K Beller and R F Weir (eds) The Beginning of Human Life Dordrecht Kluwer Academic Publishers 1994 With kind pershymission from Springer Science+Business Media

29 R M Hare ldquoThe Abnormal Child Moral Dilemmas of Doctors and Parentsrdquo Reprinted in Essays on Bioethics Oxford Clarendon Press 1993 pp185ndash91 Courtesy of the Estate of R M Hare

30 Alison Davis ldquoRight to Life of Handicappedrdquo p 181 from Journal of Medical Ethics 9 (1983) Reproduced with permission from BMJ Publishing Group

31 Christine Overall ldquoConjoined Twins Embodied Personhood and Surgical Separationrdquo pp 69ndash84 from L Tessman (ed) Feminist Ethics and Social and Political Philosophy Theorizing the Non‐Ideal Springer 2009 With kind permission from Springer Science+Business Media

32 Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death ldquolsquoA Definition of Irreversible Comarsquo Report to Examine the Definition of Brain

xiv acknowledgments

Deathrdquo pp 85ndash8 from Journal of the American Medical Association 205 6 (August 1968) Copyright copy 1968 American Medical Association All rights reserved

33 Ari Joffe ldquoAre Recent Defences of the Brain Death Concept Adequaterdquo pp 47ndash53 from Bioethics 24 2 (February 2010) Reproduced with permission from John Wiley amp Sons

34 Peter Singer ldquoIs the Sanctity of Life Ethic Terminally Illrdquo pp 307ndash43 from Bioethics 9 34 (1995) Reproduced with permission from John Wiley amp Sons

35 Ronald Dworkin ldquoLife Past Reasonrdquo pp 218ndash29 from Lifersquos Dominion An Argument about Abortion Euthanasia and Individual Freedom New York Knopf 1993 Copyright copy 1993 by Ronald Dworkin Used by permission of Alfred A Knopf an imprint of the Knopf Doubleday Publishing Group a division of Random House LLC All rights reserved

36 Rebecca Dresser ldquoDworkin on Dementia Elegant Theory Questionable Policyrdquo pp 32ndash8 from Hastings Center Report 25 6 (NovemberDecember 1995) Reproduced with permission from John Wiley amp Sons

37 Chris Hill ldquoThe Noterdquo pp 9ndash17 from Helga Kuhse (ed) Willing to Listen Wanting to Die Ringwood Australia Penguin Books 1994

38 Daniel Callahan ldquoWhen Self‐Determination Runs Amokrdquo pp 52ndash5 from Hastings Center Report 22 2 (MarchApril 1992) Reproduced with permission from John Wiley amp Sons

39 John Lachs ldquoWhen Abstract Moralizing Runs Amokrdquo pp 10ndash13 from The Journal of Clinical Ethics 5 1 (Spring 1994) Copyright JCE

40 Bregje D Onwuteaka‐Philipsen et al ldquoTrends in End‐Of‐Life Practices Before and After the Enactment of the Euthanasia Law in the Netherlands from 1990 to 2010 A Repeated Cross‐Sectional Surveyrdquo pp 908ndash15 from The Lancet 380 9845 (2012) Reprinted from The Lancet with permission from Elsevier

41 Bernard Lo ldquoEuthanasia in the Netherlands What Lessons for Elsewhererdquo pp 869ndash70 from The Lancet 380 (September 8 2012) Copyright 2012 Reprinted from The Lancet with permisshysion from Elsevier

42 Paul T Menzel ldquoRescuing Lives Canrsquot We Countrdquo pp 22ndash3 from Hastings Center Report 24 1 (1994) Reproduced with permission from John Wiley amp Sons

43 Alvin H Moss and Mark Siegler ldquoShould Alcoholics Compete Equally for Liver Transshyplantationrdquo pp 1295ndash8 from Journal of the American Medical Association 265 10 (1991) Copyright copy 1991 American Medical Association All rights reserved

44 John Harris ldquoThe Value of Liferdquo pp 87ndash102 from The Value of Life London Routledge 1985 Copyright 1985 Routledge Reproduced by permission of Taylor amp Francis Books UK

45 Nick Beckstead and Toby Ord ldquoBubbles under the Wallpaper Healthcare Rationing and Disshycriminationrdquo a paper presented to the confershyence ldquoValuing Livesrdquo New York University March 5 2011 copy Nick Beckstead and Toby Ord reprinted by permission of the authors This paper is published here for the first time but draws on Nick Beckstead and Toby Ord ldquoRationing and Rationality The Cost of Avoiding Discriminationrdquo in N Eyal et al (eds) Inequalities in Health Concepts Measures and Ethics Oxford Oxford University Press 2013 pp 232ndash9 By permission of Oxford University Press

46 Eike‐Henner W Kluge ldquoOrgan Donation and Retrieval Whose Body Is It Anywayrdquo copy 1999 by Eike‐Henner W Kluge

47 Janet Radcliffe‐Richards et al ldquoThe Case for Allowing Kidney Salesrdquo pp 1950ndash2 from The Lancet 351 9120 (June 27 1998) Reprinted with permission from Elsevier

48 Debra Satz ldquoEthical Issues in the Supply and Demand of Human Kidneysrdquo pp 189ndash206 from Why Some Things Should Not Be for Sale The Moral Limits of Markets New York Oxford University Press 2010 ch 9 based on an article from Proceedings of the Aristotelian Society Reprinted by courtesy of the Editor of Proceedings of the Aristotelian Society copy 2010

49 John Harris ldquoThe Survival Lotteryrdquo pp 81ndash7 from Philosophy 50 (1975) copy Royal Institute of Philosophy published by Cambridge University Press Reproduced with permission

Acknowledgments xv

50 Henry K Beecher ldquoEthics and Clinical Researchrdquo pp 1354ndash60 from New England Journal of Medicine 274 24 (June 1966) Copyright copy 1996 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

51 Benjamin Freedman ldquoEquipoise and the Ethics of Clinical Researchrdquo pp 141ndash5 from New England Journal of Medicine 317 3 (July 1987) Copyright copy 1987 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

52 Samuel Hellman ldquoThe Patient and the Public Goodrdquo pp 400ndash2 from Nature Medicine 1 5 (1995) Reprinted by permission from Macmillan Publishers Ltd

53 John Harris ldquoScientific Research Is a Moral Dutyrdquo pp 242ndash8 from Journal of Medical Ethics 31 4 (2005) Reproduced with permission from BMJ Publishing Group

54 Sandra Shapshay and Kenneth D Pimple ldquoParticipation in Research Is an Imperfect Moral Duty A Response to John Harrisrdquo pp 414ndash17 from Journal of Medical Ethics 33 (2007) Reproduced with permission from BMJ Publishing Group

55 Peter Lurie and Sidney M Wolfe ldquoUnethical Trials of Interventions to Reduce Perinatal Transmission of the Human Immunodeficiency Virus in Developing Countriesrdquo pp 853ndash6 from New England Journal of Medicine 337 12 (September 1997) Copyright copy 1997 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

56 Danstan Bageda and Philippa Musoke‐Mudido ldquoWersquore Trying to Help Our Sickest People Not Exploit Themrdquo from The Washington Post September 28 1997 copy 1997 Washington Post Company All rights reserved Used by permisshysion and protected by the Copyright Laws of the United States The printing copying redistribushytion or retransmission of this Content without express written permission is prohibited

57 Leah Belsky and Henry S Richardson ldquoMedical Researchersrsquo Ancillary Clinical Care Respon sibilitiesrdquo pp 1494ndash6 from British

Medical Journal 328 (June 19 2004) Reproduced with permission from BMJ Publishing Group

58 George W Bush ldquoPresident Discusses Stem Cell Researchrdquo Office of the Press Secretary White House August 9 2001

59 Jeff McMahan ldquoKilling Embryos for Stem Cell Researchrdquo pp 170ndash89 from Metaphilosophy 38 23 (2007) Reproduced with permission from John Wiley amp Sons

60 Immanuel Kant ldquoDuties towards Animalsrdquo pp 239ndash41 from Lectures on Ethics trans Louis Infield London Methuen 1930 Copyright 1930 Methuen reproduced by permission of Taylor amp Francis Books UK

61 Jeremy Bentham ldquoA Utilitarian Viewrdquo section XVIII IV from An Introduction to the Principles of Morals and Legislation First published c1820

62 Peter Singer ldquoAll Animals are Equalrdquo pp 103ndash16 from Philosophic Exchange 1 5 (1974) Center for Philosophic Exchange State University of New York Brockford NY 1974

63 R G Frey and Sir William Paton ldquoVivisection Morals and Medicine An Exchangerdquo pp 94ndash7 and 102ndash4 from Journal of Medical Ethics 9 (1983) Reproduced with permission from BMJ Publishing Group

64 Michael J Selgelid ldquoEthics and Infectious Diseaserdquo pp 272ndash89 from Bioethics 19 3 (2005) Reproduced with permission from John Wiley amp Sons

65 Udo Schuumlklenk and Anita Kleinsmidt ldquoRethinking Mandatory HIV Testing during Pregnancy in Areas with High HIV Prevalence Rates Ethical and Policy Issuesrdquo pp 1179ndash83 from American Journal of Public Health 97 7 (2007) Reproduced with permission from American Public Health Association

66 Russell Armstrong ldquoMandatory HIV Testing in Pregnancy Is There Ever a Timerdquo pp 1ndash10 from Developing World Bioethics 8 1 (2008) Reproduced with permission from John Wiley amp Sons

67 Jerome Amir Singh Ross Upshur and Nesri Padayatchi ldquoXDR‐TB in South Africa No Time for Denial or Complacencyrdquo PLoS Med 4 1 (2007) e50 doi101371journalpmed0040050 Copyright copy 2007 Singh et al

xvi acknowledgments

68 Mark Siegler ldquoConfidentiality in Medicine A Decrepit Conceptrdquo pp 1518ndash21 from New England Journal of Medicine 307 24 (December 1982) Copyright copy 1982 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

69 Christian Saumlfken and Andreas Frewer ldquoThe Duty to Warn and Clinical Ethics Legal and Ethical Aspects of Confidentiality and HIVAIDSrdquo pp 313ndash326 from HEC Forum 19 4 (2007) With kind permission from Springer Science+Business Media

70 Immanuel Kant ldquoOn a Supposed Right to Lie from Altruistic Motivesrdquo pp 361ndash3 from Critique of Practical Reason and Other Works on the Theory of Ethics 6th edition trans T K Abbott London 1909 This essay was first published in a Berlin periodical in 1797

71 Joseph Collins ldquoShould Doctors Tell the Truthrdquo pp 320ndash6 from Harperrsquos Monthly Magazine 155 (August 1927) Copyright copy 1927 Harperrsquos Magazine All rights reserved Reproduced from the August issue by special permission

72 Roger Higgs ldquoOn Telling Patients the Truthrdquo pp 186ndash202 and 232ndash3 from Michael Lockwood (ed) Moral Dilemmas in Modern Medicine Oxford Oxford University Press 1985 By permission of Oxford University Press

73 John Stuart Mill ldquoOn Libertyrdquo first published in 1859

74 Justice Benjamin N Cardozo Judgment from Schloendorff v New York Hospital (1914) p 526 from Jay Katz (ed) Experimentation with Human Beings The Authority of the Investigator Subject Professions and State in the Human Experimentation Process New York Russell Sage Foundation 1972 Reproduced with permission of Russell Sage Foundation

75 Tom L Beauchamp ldquoInformed Consent Its History Meaning and Present Challengesrdquo pp 515ndash23 from Cambridge Quarterly of Health Care Ethics 20 4 (2011) copy Royal Institute of Philosophy published by Cambridge University Press Reproduced with permission from Cambridge University Press and T Beauchamp

76 Ruth Macklin ldquoThe DoctorndashPatient Relationshyship in Different Culturesrdquo pp 86ndash107 from

Against Relativism Cultural Diversity and the Search of Ethical Universals in Medicine copy 1999 by Oxford University Press Inc By permission of Oxford University Press USA

77 Carl Elliott ldquoAmputees by Choicerdquo pp 208ndash10 210ndash15 219ndash23 227ndash31 234ndash6 323ndash6 from Better Than Well American Medicine Meets the American Dream New York and London WW Norton 2003 Copyright copy 2003 by Carl Elliott Used by permission of W W Norton amp Company Inc

78 Julian Savulescu ldquoRational Desires and the Limishytation of Life‐Sustaining Treatmentrdquo pp 191ndash 222 from Bioethics 8 3 (1994) Reproduced with permission from John Wiley amp Sons

79 Shlomo Cohen ldquoThe Nocebo Effect of Informed Consentrdquo pp 147ndash54 from Bioethics 28 3 (2014) Reproduced with permission from John Wiley amp Sons

80 Sarah E Dock ldquoThe Relation of the Nurse to the Doctor and the Doctor to the Nurserdquo p 394 (extract) from The American Journal of Nursing 17 5 (1917)

81 Lisa H Newton ldquoIn Defense of the Traditional Nurserdquo pp 348ndash54 from Nursing Outlook 29 6 (1981) Copyright Elsevier 1981

82 Sarah Breier ldquoPatient Autonomy and Medical Paternity Can Nurses Help Doctors to Listen to Patientsrdquo pp 510ndash21 from Nursing Ethics 8 6 (2001) Reproduced with permission from Sage and S Breier

83 Carol Pavlish Anita Ho and Ann‐Marie Rounkle ldquoHealth and Human Rights Advocacy Perspectives from a Rwandan Refugee Camprdquo pp 538ndash49 from Nursing Ethics 19 4 (2012) Copyright copy 2012 by SAGE Publications Reprinted by Permission of SAGE

84 Jonathan D Moreno ldquoNeuroethics An Agenda for Neuroscience and Societyrdquo pp 149ndash53 from Nature Reviews 4 (February 2003)Reprinted by permission from Macmillan Publishers Ltd

85 Sally Adee ldquoHow Electrical Brain Stimulation Can Change the Way We Thinkrdquo The Week March 30 2012

86 Neil Levy ldquoNeuroethics Ethics and the Sciences of the Mindrdquo pp 69ndash74 (extract) from Philosophy

Acknowledgments xvii

Compass 4 10 (2009) pp 69ndash81 Reproduced with permission from John Wiley amp Sons

87 Adam Kolber ldquoFreedom of Memory Todayrdquo pp 145ndash8 from Neuroethics 1 (2008) With kind permission from Springer Science+Business Media

88 Henry Greely and Colleagues ldquoTowards Responsible Use of Cognitive‐Enhancing Drugs

by the Healthyrdquo pp 702ndash5 from Nature 456 (December 11 2008) Reprinted by permission from Macmillan Publishers Ltd

89 Julian Savulescu and Anders Sandberg ldquoEngineering LoverdquoldquoLove Machine Engineering Lifelong Romancerdquo pp 28ndash9 from New Scientist 2864 copy 2012 Reed Business Information ndash UK All rights reserved Distributed by Tribune Content Agency

Bioethics An Anthology Third Edition Edited by Helga Kuhse Udo Schuumlklenk and Peter Singer copy 2016 John Wiley amp Sons Inc Published 2016 by John Wiley amp Sons Inc

Introduction

The term ldquobioethicsrdquo was coined by Van Rensselaer Potter who used it to describe his proposal that we need an ethic that can incorporate our obligations not just to other humans but to the biosphere as a whole1 Although the term is still occasionally used in this sense of an ecological ethic it is now much more commonly used in the narrower sense of the study of ethical issues arising from the biological and medical sciences So understood bioethics has become a specialized although interdisciplinary area of study The essays included in this book give an indication of the range of issues which fall within its scope ndash but it is only an indication There are many other issues that we simply have not had the space to cover

Bioethics can be seen as a branch of ethics or more specifically of applied ethics For this reason some understanding of the nature of ethics is an essential preliminary to any serious study of bioethics The remainder of this introduction will seek to provide that understanding

One question about the nature of ethics is especially relevant to bioethics to what extent is reasoning or argument possible in ethics Many people assume without much thought that ethics is subjective The subjectivist holds that what ethical view we take is a matter of opinion or taste that is not amenable to argument But if ethics were a matter of taste why would we even attempt to argue about it If Helen says ldquoI like my coffee sweetenedrdquo whereas Paul says

ldquoI like my coffee unsweetenedrdquo there is not much point in Helen and Paul arguing about it The two statements do not contradict each other They can both be true But if Helen says ldquoDoctors should never assist their patients to dierdquo whereas Paul says ldquoSometimes doctors should assist their patients to dierdquo then Helen and Paul are disagreeing and there does seem to be a point in their trying to argue about the issue of physician‐assisted suicide

It seems clear that there is some scope for argument in ethics If I say ldquoIt is always wrong to kill a human beingrdquo and ldquoAbortion is not always wrongrdquo then I am committed to denying that abortion kills a human being Otherwise I have contradicted myself and in doing so I have not stated a coherent position at all So consistency at least is a requirement of any defensible ethical position and thus sets a limit to the subjectivity of ethical judgments The requirement of factual accuracy sets another limit In discussing issues in bioethics the facts are often complex But we cannot reach the right ethical decisions unless we are well‐informed about the relevant facts In this respect ethical decisions are unlike decisions of taste We can enjoy a taste without knowing what we are eating but if we assume that it is wrong to resuscitate a terminally ill patient against her wishes then we can-not know whether an instance of resuscitation was morally right or wrong without knowing something about the patientrsquos prognosis and whether the patient

2 introduction

has expressed any wishes about being resuscitated In that sense there is no equivalent in ethics to the immediacy of taste

Ethical relativism sometimes also known as cul-tural relativism is one step away from ethical sub-jectivism but it also severely limits the scope of ethical argument The ethical relativist holds that it is not individual attitudes that determine what is right or wrong but the attitudes of the culture in which one lives Herodotus tells how Darius King of Persia summoned the Greeks from the western shores of his kingdom before him and asked them how much he would have to pay them to eat their fathersrsquo dead bodies They were horrified by the idea and said they would not do it for any amount of money for it was their custom to cremate their dead Then Darius called upon Indians from the eastern frontiers of his kingdom and asked them what would make them willing to burn their fathersrsquo bodies They cried out and asked the King to refrain from mentioning so shocking an act Herodotus comments that each nation thinks its own customs best From here it is only a short step to the view that there can be no objective right or wrong beyond the bounds of onersquos own culture This view found increased support in the nine-teenth century as Western anthropologists came to know many different cultures and were impressed by ethical views very different from those that were standardly taken for granted in European society As a defense against the automatic assumption that Western morality is superior and should be imposed on ldquosavagesrdquo many anthropologists argued that since morality is relative to culture no culture can have any basis for regarding its morality as superior to any other culture

Although the motives with which anthropolo-gists put this view forward were admirable they may not have appreciated the implications of the position they were taking The ethical relativist maintains that a statement like ldquoIt is good to enslave people from another tribe if they are captured in warrdquo means simply ldquoIn my society the custom is to enslave people from another tribe if they are cap-tured in warrdquo Hence if one member of the society were to question whether it really was good to enslave people in these circumstances she could be

answered simply by demonstrating that this was indeed the custom ndash for example by showing that for many generations it had been done after every war in which prisoners were captured Thus there is no way for moral reformers to say that an accepted custom is wrong ndash ldquowrongrdquo just means ldquoin accord-ance with an accepted customrdquo

On the other hand when people from two different cultures disagree about an ethical issue then according to the ethical relativist there can be no resolution of the disagreement Indeed strictly there is no disagree-ment If the apparent dispute were over the issue just mentioned then one person would be saying ldquoIn my country it is the custom to enslave people from another tribe if they are captured in warrdquo and the other person would be saying ldquoIn my country it is not the custom to allow one human being to enslave anotherrdquo This is no more a disagreement than such statements as ldquoIn my country people greet each other by rubbing nosesrdquo and ldquoIn my country people greet each other by shaking handsrdquo If ethical relativism is true then it is impossible to say that one culture is right and the other is wrong Bearing in mind that some cultures have practiced slavery or the burning of widows on the funeral pyre of their husbands this is hard to accept

A more promising alternative to both ethical subjectivism and cultural relativism is universal pre-scriptivism an approach to ethics developed by the Oxford philosopher R M Hare Hare argues that the distinctive property of ethical judgments is that they are universalizable In saying this he means that if I make an ethical judgment I must be prepared to state it in universal terms and apply it to all relevantly similar situations By ldquouniversal termsrdquo Hare means those terms that do not refer to a particular individual Thus a proper name cannot be a universal term If for example I were to say ldquoEveryone should do what is in the interests of Mick Jaggerrdquo I would not be making a universal judgment because I have used a proper name The same would be true if I were to say that everyone must do what is in my interests because the personal pronoun ldquomyrdquo is here used to refer to a particular individual myself

It might seem that ruling out particular terms in this way does not take us very far After all one can always describe oneself in universal terms Perhaps

Introduction 3

I canrsquot say that everyone should do what is in my interests but I could say that everyone must do whatever is in the interests of people who hellip and then give a minutely detailed description of myself including the precise location of all my freckles The effect would be the same as saying that everyone should do what is in my interests because there would be no one except me who matches that description But Hare meets this problem very effectively by saying that to prescribe an ethical judgment universally means being prepared to pre-scribe it for all possible circumstances including hypothetical ones So if I were to say that everyone should do what is in the interests of a person with a particular pattern of freckles I must be prepared to prescribe that in the hypothetical situation in which I do not have this pattern of freckles but someone else does I should do what is in the interests of that person Now of course I may say that I should do that since I am confident that I shall never be in such a situation but this simply means that I am being dishonest I am not genuinely prescribing the principle universally

The effect of saying that an ethical judgment must be universalizable for hypothetical as well as actual circumstances is that whenever I make an ethical judgment I can be challenged to put myself in the position of the parties affected and see if I would still be able to accept that judgment Suppose for example that I own a small factory and the cheapest way for me to get rid of some waste is to pour it into a nearby river I do not take water from this river but I know that some villagers living downstream do and the waste may make them ill The requirement that ethical judgments should be universalizable will make it difficult for me to justify my conduct because if I imagine myself in the hypothetical situation of being one of the villagers rather than the factory‐owner I would not accept that the profits of the factory‐owner should outweigh the risk of adverse effects on my health and that of my children In this way Harersquos approach requires us to take into account the interests and preferences of all others affected by our actions Hence it allows for an element of reasoning in ethical deliberation

Since the rightness or wrongness of our actions will on this view depend on the way in which they

affect others Harersquos universal prescriptivism leads to a form of consequentialism ndash that is the view that the rightness of an action depends on its consequences The best‐known form of consequentialism is the clas-sical utilitarianism developed in the late eighteenth century by Jeremy Bentham and popularized in the nineteenth century by John Stuart Mill They held that an action is right if it leads to a greater surplus of happiness over misery than any possible alternative and wrong if it does not By ldquogreater surplus of happinessrdquo the classical utilitarians had in mind the idea of adding up all the pleasure or happiness that resulted from the action and subtracting from that total all the pain or misery to which the action gave rise Naturally in some circumstances it might be possible only to reduce misery and then the right action should be understood as the one that will result in less misery than any possible alternative

The utilitarian view is striking in many ways It puts forward a single principle that it claims can provide the right answer to all ethical dilemmas if only we can predict what the consequences of our actions will be It takes ethics out of the mysterious realm of duties and rules and bases ethical decisions on something that almost everyone understands and values Moreover utilitarianismrsquos single principle is applied universally without fear or favor Bentham said ldquoEach to count for one and none for more than onerdquo by which he meant that the happiness of a com-mon tramp counted for as much as that of a noble and the happiness of an African was no less important than that of a European

Many contemporary consequentialists agree with Bentham to the extent that they think the rightness or wrongness of an action must depend on its conse-quences but they have abandoned the idea that m aximizing net happiness is the ultimate goal Instead they argue that we should seek to bring about w hatever will satisfy the greatest number of desires or preference This variation which is known as ldquop reference utilitarianismrdquo does not regard anything as good except in so far as it is wanted or desired More intense or strongly held preferences would get more weight than weak preferences

Consequentialism offers one important answer to the question of how we should decide what is right and what is wrong but many ethicists reject it The

4 introduction

denial of this view was dramatically presented by Dostoevsky in The Karamazov Brothers

imagine that you are charged with building the edifice of human destiny the ultimate aim of which is to bring people happiness to give them peace and contentment at last but that in order to achieve this it is essential and unavoidable to torture just one little speck of creation that same little child beating her chest with her little fists and imagine that this edifice has to be erected on her unexpiated tears Would you agree to be the architect under those conditions Tell me honestly2

The passage suggests that some things are always wrong no matter what their consequences This has for most of Western history been the prevailing approach to morality at least at the level of what has been officially taught and approved by the institutions of Church and State The ten commandments of the Hebrew scriptures served as a model for much of the Christian era and the Roman Catholic Church built up an elaborate system of morality based on rules to which no exceptions were allowed

Another example of an ethic of rules is that of Immanuel Kant Kantrsquos ethic is based on his ldquocategori-cal imperativerdquo which he states in several distinct for-mulations One is that we must always act so that we can will the maxim of our action to be a universal law This can be interpreted as a form of Harersquos idea of universalizability which we have already encountered Another is that we must always treat other people as ends never as means While these formulations of the categorical imperative might be applied in various ways in Kantrsquos hands they lead to inviolable rules for example against making promises that we do not intend to keep Kant also thought that it was always wrong to tell a lie In response to a critic who sug-gested that this rule has exceptions Kant said that it would be wrong to lie even if someone had taken refuge in your house and a person seeking to murder him came to your door and asked if you knew where he was Modern Kantians often reject this hard-line approach to rules and claim that Kantrsquos categorical imperative did not require him to hold so strictly to the rule against lying

How would a consequentialist ndash for example a classical utilitarian ndash answer Dostoevskyrsquos challenge If answering honestly ndash and if one really could be certain

that this was a sure way and the only way of bringing lasting happiness to all the people of the world ndash utilitarians would have to say yes they would accept the task of being the architect of the happiness of the world at the cost of the childrsquos unexpiated tears For they would point out that the suffering of that child wholly undeserved as it is will be repeated a million‐fold over the next century for other children just as innocent who are victims of starvation disease and brutality So if this one child must be sacrificed to stop all this suffering then terrible as it is the child must be sacrificed

Fantasy apart there can be no architect of the hap-piness of the world The world is too big and complex a place for that But we may attempt to bring about less suffering and more happiness or satisfaction of preferences for people or sentient beings in specific places and circumstances Alternatively we might fol-low a set of principles or rules ndash which could be of varying degrees of rigidity or flexibility Where would such rules come from Kant tried to deduce them from his categorical imperative which in turn he had reached by insisting that the moral law must be based on reason alone without any content from our wants or desires But the problem with trying to deduce morality from reason alone has always been that it becomes an empty formalism that cannot tell us what to do To make it practical it needs to have some addi-tional content and Kantrsquos own attempts to deduce rules of conduct from his categorical imperative are unconvincing

Others following Aristotle have tried to draw on human nature as a source of moral rules What is good they say is what is natural to human beings They then contend that it is natural and right for us to seek certain goods such as knowledge friendship health love and procreation and unnatural and wrong for us to act contrary to these goods This ldquonatural lawrdquo ethic is open to criticism on several points The word ldquonaturalrdquo can be used both descriptively and evalua-tively and the two senses are often mixed together so that value judgments may be smuggled in under the guise of a description The picture of human nature presented by proponents of natural law ethics usually selects only those characteristics of our nature that the proponent considers desirable The fact that our species especially its male members frequently go to war and

Introduction 5

are also prone to commit individual acts of violence against others is no doubt just as much part of our nature as our desire for knowledge but no natural law theorist therefore views these activities as good More generally natural law theory has its origins in an Aristotelian idea of the cosmos in which everything has a goal or ldquoendrdquo which can be deduced from its nature The ldquoendrdquo of a knife is to cut the assumption is that human beings also have an ldquoendrdquo and we will flourish when we live in accordance with the end for which we are suited But this is a pre‐Darwinian view of nature Since Darwin we know that we do not exist for any purpose but are the result of natural selection operating on random mutations over millions of years Hence there is no reason to believe that living accord-ing to nature will produce a harmonious society let alone the best possible state of affairs for human beings

Another way in which it has been claimed that we can come to know what moral principles or rules we should follow is through our intuition In practice this usually means that we adopt conven-tionally accepted moral principles or rules perhaps with some adjustments in order to avoid inconsist-ency or arbitrariness On this view a moral theory should like a scientific theory try to match the data and the data that a moral theory must match is p rovided by our moral intuitions As in science if a plausible theory matches most but not all of the data then the anomalous data might be rejected on the grounds that it is more likely that there was an error in the procedures for gathering that particular set of data than that the theory as a whole is mis-taken But ultimately the test of a theory is its ability to explain the data The problem with applying this model of scientific justification to ethics is that the ldquodatardquo of our moral intuitions is unreliable not just at one or two specific points but as a whole Here the facts that cultural relativists draw upon are rele-vant (even if they do not establish that cultural rela-tivism is the correct response to it) Since we know that our intuitions are strongly influenced by such things as culture and religion they are ill‐suited to serve as the fixed points against which an ethical theory must be tested Even where there is cross‐cultural agreement there may be some aspects of our intuitions on which all cultures unjustifiably favor our own interests over those of others For

example simply because we are all human beings we may have a systematic bias that leads us to give an unjustifiably low moral status to nonhuman a nimals Or because in virtually all known human societies men have taken a greater leadership role than women the moral intuitions of all societies may not adequately reflect the interests of females

Some philosophers think that it is a mistake to base ethics on principles or rules Instead they focus on what it is to be a good person ndash or in the case of the problems with which this book is concerned perhaps on what it is to be a good nurse or doctor or researcher They seek to describe the virtues that a good person or a good member of the relevant profession should possess Moral education then consists of teaching these virtues and discussing how a virtuous person would act in specific situations The question is how-ever whether we can have a notion of what a virtuous person would do in a specific situation without making a prior decision about what it is right to do After all in any particular moral dilemma different virtues may be applicable and even a particular virtue will not always give unequivocal guidance For instance if a terminally ill patient repeatedly asks a nurse or doctor for assistance in dying what response best exemplifies the virtues of a healthcare professional There seems no answer to this question short of an inquiry into whether it is right or wrong to help a patient in such circumstances to die But in that case we seem bound in the end to come back to discuss-ing such issues as whether it is right to follow moral rules or principles or to do what will have the best consequences

In the late twentieth century some feminists offered new criticisms of conventional thought about ethics They argued that the approaches to ethics taken by the influential philosophers of the past ndash all of whom have been male ndash give too much emphasis to abstract principles and the role of reason and give too little attention to personal relationships and the part played by emotion One outcome of these criticisms has been the development of an ldquoethic of carerdquo which is not so much a single ethical theory as a cluster of ways of looking at ethics which put an attitude of c aring for others at the center and seek to avoid r eliance on abstract ethical principles The ethic of care has seemed especially applicable to the work of those

6 introduction

involved in direct patient care and has recently been taken up by a number of nursing theorists as offering a more suitable alternative to other ideas of ethics Not all feminists however support this development Some worry that the adoption of a ldquocarerdquo approach by nurses may reflect and even reinforce stereotypes of women as more emotional and less rational than men They also fear that it could lead to women continuing to carry a disproportionate burden of caring for others to the exclusion of adequately caring for themselves

In this discussion of ethics we have not mentioned anything about religion This may seem odd in view of the close connection that has often been made between religion and ethics but it reflects our belief that despite this historical connection ethics and reli-gion are fundamentally independent Logically ethics is prior to religion If religious believers wish to say that a deity is good or praise her or his creation or deeds they must have a notion of goodness that is independent of their conception of the deity and what she or he does Otherwise they will be saying that the deity is good and when asked what they mean by ldquogoodrdquo they will have to refer back to the deity saying perhaps that ldquogoodrdquo means ldquoin accord-ance with the wishes of the deityrdquo In that case sen-tences such as ldquoGod is goodrdquo would be a meaningless tautology ldquoGod is goodrdquo could mean no more than ldquoGod is in accordance with Godrsquos wishesrdquo As we have already seen there are ideas of what it is for something to be ldquogoodrdquo that are not rooted in any religious belief While religions typically encourage or instruct their followers to obey a particular ethical code it is obvious that others who do not follow any religion can also think and act ethically

To say that ethics is independent of religion is not to deny that theologians or other religious believers may have a role to play in bioethics Religious traditions often have long histories of dealing with ethical dilem-mas and the accumulation of wisdom and experience that they represent can give us valuable insights into particular problems But these insights should be subject to criticism in the way that any other proposals would be If in the end we accept them it is because we have judged them sound not because they are the utterances of a pope a rabbi a mullah or a holy person

Ethics is also independent of the law in the sense that the rightness or wrongness of an act cannot be

settled by its legality or illegality Whether an act is legal or illegal may often be relevant to whether it is right or wrong because it is arguably wrong to break the law other things being equal Many people have thought that this is especially so in a democracy in which everyone has a say in making the law Another reason why the fact that an act is illegal may be a rea-son against doing it is that the legality of an act may affect the consequences that are likely to flow from it If active voluntary euthanasia is illegal then doctors who practice it risk going to jail which will cause them and their families to suffer and also mean that they will no longer be able to help other patients This can be a powerful reason for not practicing voluntary euthanasia when it is against the law but if there is only a very small chance of the offense becoming known or being proved then the weight of this con-sequentialist reason against breaking the law is reduced accordingly Whether we have an ethical obligation to obey the law and if so how much weight should be given to it is itself an issue for ethical argument

Though ethics is independent of the law in the sense just specified laws are subject to evaluation from an ethical perspective Many debates in bioethics focus on questions about what practices should be allowed ndash for example should we allow research on stem cells taken from human embryos sex selection or cloning ndash and committees set up to advise on the ethical social and legal aspects of these questions often recommend legislation to prohibit the activity in question or to allow it to be practiced under some form of regulation Discussing a question at the level of law and public policy however raises somewhat different considerations than a discussion of personal ethics because the consequences of adopting a public policy generally have much wider ramifications than the consequences of a personal choice That is why some healthcare professionals feel justified in assisting a terminally ill patient to die while at the same time opposing the legalization of physician‐assisted suicide Paradoxical as this position may appear ndash and it is certainly open to criticism ndash it is not straightforwardly inconsistent

Naturally many of the essays we have selected reflect the times in which they were written Since bioethics often comments on developments in fast‐moving

Introduction 7

areas of medicine and the biological sciences the factual content of articles in bioethics can become obsolete quite rapidly In preparing this revised edition we have taken the opportunity to cover some new issues and to include some more recent writings We have for example included new mate-rial on genetic enhancement as well as on the use of embryonic human stem cells This edition of the anthology also includes new sections on ethical issues in public health and in the neurosciences Nevertheless an article that has dated in regard to its facts often makes ethical points that are still valid

or worth considering so we have not excluded older articles for this reason

Other articles are dated in a different way During the past few decades we have become more sensitive about the ways in which our language may exclude women or reflect our prejudices regarding race or sexuality We see no merit in trying to disguise past practices on such matters so we have not excluded otherwise valuable works in bioethics on these grounds If they are jar-ring to the modern reader that may be a salutary reminder of the extent to which we all are subject to the conventions and prejudices of our times

Notes

1 See Van Rensselaer Potter Bioethics Bridge to the Future (Englewood Cliffs NJ Prentice‐Hall 1971)

2 The Karamazov Brothers trans Ignat Avsey (Oxford Oxford University Press 1994) vol I part 2 bk 5 ch 4 First published in 1879

Abortion

Part I

Contents xi

82 Patient Autonomy and Medical Paternity Can Nurses Help Doctors to Listen to Patients 708Sarah Breier

83 Health and Human Rights Advocacy Perspectives from a Rwandan Refugee Camp 718Carol Pavlish Anita Ho and Ann‐Marie Rounkle

Part XII Neuroethics 729

Introduction 731

84 Neuroethics An Agenda for Neuroscience and Society 733Jonathan D Moreno

85 How Electrical Brain Stimulation Can Change the Way We Think 741Sally Adee

86 Neuroethics Ethics and the Sciences of the Mind 744Neil Levy

87 Freedom of Memory Today 749Adam Kolber

88 Towards Responsible Use of Cognitive‐Enhancing Drugs by the Healthy 753Henry Greely Barbara Sahakian John Harris Ronald C Kessler Michael Gazzaniga Philip Campbell and Martha J Farah

89 Engineering Love 760Julian Savulescu and Anders Sandberg

Index 762

Acknowledgments

The editor and publisher gratefully acknowledge the permission granted to reproduce the copyright material in this book

1 John Finnis ldquoAbortion and Health Care Ethicsrdquo pp 547ndash57 from Raanan Gillon (ed) Principles of Health Care Ethics Chichester John Wiley 1994 Reproduced with permission from John Wiley amp Sons

2 Michael Tooley ldquoAbortion and Infanticiderdquo pp 37ndash65 from Philosophy and Public Affairs 1 (1972) Reproduced with permission from John Wiley amp Sons

3 Judith Jarvis Thomson ldquoA Defense of Abortionrdquo pp 47ndash66 from Philosophy and Public Affairs 1 1 (1971) Reproduced with permission from John Wiley amp Sons

4 Don Marquis ldquoWhy Abortion Is Immoralrdquo Journal of Philosophy 86 4 (April 1989) 183ndash202

5 Gregory Pence ldquoMultiple Gestation and Damaged Babies Godrsquos Will or Human Choicerdquo This essay draws on ldquoThe McCaughey Septuplets Godrsquos Will or Human Choicerdquo pp 39ndash43 from Gregory Pence Brave New Bioethics Lanham MD Rowman amp Littlefield 2002 copy Gregory Pence 2002 Courtesy of G Pence

6 Dorothy A Greenfeld and Emre Seli ldquoAssisted Reproduction in Same Sex Couplesrdquo pp 289ndash301 from M V Sauer (ed) Principles of Oocyte and Embryo Donation Springer‐Verlag 2013 With kind permisshysion from Springer Science+Business Media

7 Derek Parfit ldquoRights Interests and Possible Peoplerdquo pp 369ndash75 from Samuel Gorovitz et al (eds) Moral

Problems in Medicine Englewood Cliffs NJ Prentice Hall 1976 Courtesy of D Parfit

8 Ruby Catsanos Wendy Rogers and Mianna Lotz ldquoThe Ethics of Uterus Transplantationrdquo pp 65ndash73 from Bioethics 27 2 (2013) Reproduced by permission of John Wiley amp Sons

9 Laura M Purdy ldquoGenetics and Reproductive Risk Can Having Children be Immoralrdquo pp 39ndash49 from Reproducing Persons Issues in Feminist Bioethics Ithaca NY Cornell University Press 1996 Reproduced with permission from Cornell University Press

10 Adrienne Asch ldquoPrenatal Diagnosis and Selective Abortion A Challenge to Practice and Policyrdquo pp 1649ndash57 from American Journal of Public Health 89 11 (1999) Reproduced with permisshysion from American Public Health Association

11 Ruth Chadwick and Mairi Levitt ldquoGenetic Technology A Threat to Deafnessrdquo pp 209ndash15 from Medicine Healthcare and Philosophy 1 (1998) With kind permission from Springer Science+ Business Media

12 The Ethics Committee of the American Society of Reproductive Medicine ldquoSex Selection and Preimplantation Genetic Diagnosisrdquo pp 595ndash8 from Fertility and Sterility 72 4 (October 1999) Reprinted with permission from Elsevier

13 Julian Savulescu and Edgar Dahl ldquoSex Selection and Preimplantation Diagnosis A Response to the Ethics Committee of the American Society of Reproductive Medicinerdquo pp 1879ndash80 from Human Reproduction 15 9 (2000) By permission of Oxford University Press

Acknowledgments xiii

14 John A Robertson Jeffrey P Kahn and John E Wagner ldquoConception to Obtain Hematopoietic Stem Cellsrdquo pp 34ndash40 from Hastings Center Report 32 3 (MayJune 2002) Reproduced with permission from John Wiley amp Sons

15 David King ldquoWhy We Should Not Permit Embryos to Be Selected as Tissue Donorsrdquo pp 13ndash16 from The Bulletin of Medical Ethics 190 (August 2003) Copyright copy RSM Press 2003 Reproduced by permission of SAGE Publications Ltd London Los Angeles New Delhi Singapore and Washington DC

16 Michael Tooley ldquoThe Moral Status of the Cloning of Humansrdquo pp 67ndash101 from James M Humber and Robert I Almeder (eds) Human Cloning Totowa NJ Humana Press 1998 With kind permission from Springer Science+Business Media

17 Jonathan Glover ldquoQuestions about Some Uses of Genetic Engineeringrdquo pp 25ndash33 33ndash6 42ndash3 and 45ndash53 from What Sort of People Should There Be Harmondsworth Penguin Books 1984 Reproshyduced by permission of Penguin Books Ltd

18 David B Resnik ldquoThe Moral Significance of the TherapyndashEnhancement Distinction in Human Geneticsrdquo pp 365ndash77 from Cambridge Quarterly of Healthcare Ethics 9 3 (Summer 2000) copy Cambridge University Press Reproduced with permission

19 Ainsley Newson and Robert Williamson ldquoShould We Undertake Genetic Research on Intelligencerdquo pp 327ndash42 from Bioethics 13 34 (1999) Reproduced with permission from John Wiley amp Sons

20 Nick Bostrom ldquoIn Defense of Posthuman Dignityrdquo pp 202ndash14 from Bioethics 19 3 (2005) Reproduced with permission from John Wiley amp Sons

21 Jonathan Glover ldquoThe Sanctity of Liferdquo pp 39ndash59 from Causing Death and Lives London Pelican 1977 Reproduced by permission of Penguin Books Ltd

22 Sacred Congregation for the Doctrine of the Faith ldquoDeclaration on Euthanasiardquo Vatican City 1980

23 Germain Grisez and Joseph M Boyle Jr ldquoThe Morality of Killing A Traditional Viewrdquo

pp 381ndash419 from Life and Death with Liberty and Justice A Contribution to the Euthanasia Debate Notre Dame IN University of Notre Dame Press 1971

24 James Rachels ldquoActive and Passive Euthanasiardquo pp 78ndash80 from New England Journal of Medicine 292 (1975) Copyright copy 1975 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

25 Winston Nesbitt ldquoIs Killing No Worse Than Letting Dierdquo pp 101ndash5 from Journal of Applied Philosophy 12 1 (1995) Reproduced with permission from John Wiley amp Sons

26 Helga Kuhse ldquoWhy Killing Is Not Always Worse ndash and Sometimes Better ndash Than Letting Dierdquo pp 371ndash4 from Cambridge Quarterly of Healthcare 7 4 (1998) copy Cambridge University Press Reproduced with permission

27 Franklin G Miller Robert D Truog and Dan W Brock ldquoMoral Fictions and Medical Ethicsrdquo pp 453ndash60 from Bioethics 24 9 (2010) Reproduced with permission from John Wiley amp Sons

28 Neil Campbell ldquoWhen Care Cannot Cure Medical Problems in Seriously Ill Babiesrdquo pp 327ndash44 from F K Beller and R F Weir (eds) The Beginning of Human Life Dordrecht Kluwer Academic Publishers 1994 With kind pershymission from Springer Science+Business Media

29 R M Hare ldquoThe Abnormal Child Moral Dilemmas of Doctors and Parentsrdquo Reprinted in Essays on Bioethics Oxford Clarendon Press 1993 pp185ndash91 Courtesy of the Estate of R M Hare

30 Alison Davis ldquoRight to Life of Handicappedrdquo p 181 from Journal of Medical Ethics 9 (1983) Reproduced with permission from BMJ Publishing Group

31 Christine Overall ldquoConjoined Twins Embodied Personhood and Surgical Separationrdquo pp 69ndash84 from L Tessman (ed) Feminist Ethics and Social and Political Philosophy Theorizing the Non‐Ideal Springer 2009 With kind permission from Springer Science+Business Media

32 Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death ldquolsquoA Definition of Irreversible Comarsquo Report to Examine the Definition of Brain

xiv acknowledgments

Deathrdquo pp 85ndash8 from Journal of the American Medical Association 205 6 (August 1968) Copyright copy 1968 American Medical Association All rights reserved

33 Ari Joffe ldquoAre Recent Defences of the Brain Death Concept Adequaterdquo pp 47ndash53 from Bioethics 24 2 (February 2010) Reproduced with permission from John Wiley amp Sons

34 Peter Singer ldquoIs the Sanctity of Life Ethic Terminally Illrdquo pp 307ndash43 from Bioethics 9 34 (1995) Reproduced with permission from John Wiley amp Sons

35 Ronald Dworkin ldquoLife Past Reasonrdquo pp 218ndash29 from Lifersquos Dominion An Argument about Abortion Euthanasia and Individual Freedom New York Knopf 1993 Copyright copy 1993 by Ronald Dworkin Used by permission of Alfred A Knopf an imprint of the Knopf Doubleday Publishing Group a division of Random House LLC All rights reserved

36 Rebecca Dresser ldquoDworkin on Dementia Elegant Theory Questionable Policyrdquo pp 32ndash8 from Hastings Center Report 25 6 (NovemberDecember 1995) Reproduced with permission from John Wiley amp Sons

37 Chris Hill ldquoThe Noterdquo pp 9ndash17 from Helga Kuhse (ed) Willing to Listen Wanting to Die Ringwood Australia Penguin Books 1994

38 Daniel Callahan ldquoWhen Self‐Determination Runs Amokrdquo pp 52ndash5 from Hastings Center Report 22 2 (MarchApril 1992) Reproduced with permission from John Wiley amp Sons

39 John Lachs ldquoWhen Abstract Moralizing Runs Amokrdquo pp 10ndash13 from The Journal of Clinical Ethics 5 1 (Spring 1994) Copyright JCE

40 Bregje D Onwuteaka‐Philipsen et al ldquoTrends in End‐Of‐Life Practices Before and After the Enactment of the Euthanasia Law in the Netherlands from 1990 to 2010 A Repeated Cross‐Sectional Surveyrdquo pp 908ndash15 from The Lancet 380 9845 (2012) Reprinted from The Lancet with permission from Elsevier

41 Bernard Lo ldquoEuthanasia in the Netherlands What Lessons for Elsewhererdquo pp 869ndash70 from The Lancet 380 (September 8 2012) Copyright 2012 Reprinted from The Lancet with permisshysion from Elsevier

42 Paul T Menzel ldquoRescuing Lives Canrsquot We Countrdquo pp 22ndash3 from Hastings Center Report 24 1 (1994) Reproduced with permission from John Wiley amp Sons

43 Alvin H Moss and Mark Siegler ldquoShould Alcoholics Compete Equally for Liver Transshyplantationrdquo pp 1295ndash8 from Journal of the American Medical Association 265 10 (1991) Copyright copy 1991 American Medical Association All rights reserved

44 John Harris ldquoThe Value of Liferdquo pp 87ndash102 from The Value of Life London Routledge 1985 Copyright 1985 Routledge Reproduced by permission of Taylor amp Francis Books UK

45 Nick Beckstead and Toby Ord ldquoBubbles under the Wallpaper Healthcare Rationing and Disshycriminationrdquo a paper presented to the confershyence ldquoValuing Livesrdquo New York University March 5 2011 copy Nick Beckstead and Toby Ord reprinted by permission of the authors This paper is published here for the first time but draws on Nick Beckstead and Toby Ord ldquoRationing and Rationality The Cost of Avoiding Discriminationrdquo in N Eyal et al (eds) Inequalities in Health Concepts Measures and Ethics Oxford Oxford University Press 2013 pp 232ndash9 By permission of Oxford University Press

46 Eike‐Henner W Kluge ldquoOrgan Donation and Retrieval Whose Body Is It Anywayrdquo copy 1999 by Eike‐Henner W Kluge

47 Janet Radcliffe‐Richards et al ldquoThe Case for Allowing Kidney Salesrdquo pp 1950ndash2 from The Lancet 351 9120 (June 27 1998) Reprinted with permission from Elsevier

48 Debra Satz ldquoEthical Issues in the Supply and Demand of Human Kidneysrdquo pp 189ndash206 from Why Some Things Should Not Be for Sale The Moral Limits of Markets New York Oxford University Press 2010 ch 9 based on an article from Proceedings of the Aristotelian Society Reprinted by courtesy of the Editor of Proceedings of the Aristotelian Society copy 2010

49 John Harris ldquoThe Survival Lotteryrdquo pp 81ndash7 from Philosophy 50 (1975) copy Royal Institute of Philosophy published by Cambridge University Press Reproduced with permission

Acknowledgments xv

50 Henry K Beecher ldquoEthics and Clinical Researchrdquo pp 1354ndash60 from New England Journal of Medicine 274 24 (June 1966) Copyright copy 1996 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

51 Benjamin Freedman ldquoEquipoise and the Ethics of Clinical Researchrdquo pp 141ndash5 from New England Journal of Medicine 317 3 (July 1987) Copyright copy 1987 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

52 Samuel Hellman ldquoThe Patient and the Public Goodrdquo pp 400ndash2 from Nature Medicine 1 5 (1995) Reprinted by permission from Macmillan Publishers Ltd

53 John Harris ldquoScientific Research Is a Moral Dutyrdquo pp 242ndash8 from Journal of Medical Ethics 31 4 (2005) Reproduced with permission from BMJ Publishing Group

54 Sandra Shapshay and Kenneth D Pimple ldquoParticipation in Research Is an Imperfect Moral Duty A Response to John Harrisrdquo pp 414ndash17 from Journal of Medical Ethics 33 (2007) Reproduced with permission from BMJ Publishing Group

55 Peter Lurie and Sidney M Wolfe ldquoUnethical Trials of Interventions to Reduce Perinatal Transmission of the Human Immunodeficiency Virus in Developing Countriesrdquo pp 853ndash6 from New England Journal of Medicine 337 12 (September 1997) Copyright copy 1997 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

56 Danstan Bageda and Philippa Musoke‐Mudido ldquoWersquore Trying to Help Our Sickest People Not Exploit Themrdquo from The Washington Post September 28 1997 copy 1997 Washington Post Company All rights reserved Used by permisshysion and protected by the Copyright Laws of the United States The printing copying redistribushytion or retransmission of this Content without express written permission is prohibited

57 Leah Belsky and Henry S Richardson ldquoMedical Researchersrsquo Ancillary Clinical Care Respon sibilitiesrdquo pp 1494ndash6 from British

Medical Journal 328 (June 19 2004) Reproduced with permission from BMJ Publishing Group

58 George W Bush ldquoPresident Discusses Stem Cell Researchrdquo Office of the Press Secretary White House August 9 2001

59 Jeff McMahan ldquoKilling Embryos for Stem Cell Researchrdquo pp 170ndash89 from Metaphilosophy 38 23 (2007) Reproduced with permission from John Wiley amp Sons

60 Immanuel Kant ldquoDuties towards Animalsrdquo pp 239ndash41 from Lectures on Ethics trans Louis Infield London Methuen 1930 Copyright 1930 Methuen reproduced by permission of Taylor amp Francis Books UK

61 Jeremy Bentham ldquoA Utilitarian Viewrdquo section XVIII IV from An Introduction to the Principles of Morals and Legislation First published c1820

62 Peter Singer ldquoAll Animals are Equalrdquo pp 103ndash16 from Philosophic Exchange 1 5 (1974) Center for Philosophic Exchange State University of New York Brockford NY 1974

63 R G Frey and Sir William Paton ldquoVivisection Morals and Medicine An Exchangerdquo pp 94ndash7 and 102ndash4 from Journal of Medical Ethics 9 (1983) Reproduced with permission from BMJ Publishing Group

64 Michael J Selgelid ldquoEthics and Infectious Diseaserdquo pp 272ndash89 from Bioethics 19 3 (2005) Reproduced with permission from John Wiley amp Sons

65 Udo Schuumlklenk and Anita Kleinsmidt ldquoRethinking Mandatory HIV Testing during Pregnancy in Areas with High HIV Prevalence Rates Ethical and Policy Issuesrdquo pp 1179ndash83 from American Journal of Public Health 97 7 (2007) Reproduced with permission from American Public Health Association

66 Russell Armstrong ldquoMandatory HIV Testing in Pregnancy Is There Ever a Timerdquo pp 1ndash10 from Developing World Bioethics 8 1 (2008) Reproduced with permission from John Wiley amp Sons

67 Jerome Amir Singh Ross Upshur and Nesri Padayatchi ldquoXDR‐TB in South Africa No Time for Denial or Complacencyrdquo PLoS Med 4 1 (2007) e50 doi101371journalpmed0040050 Copyright copy 2007 Singh et al

xvi acknowledgments

68 Mark Siegler ldquoConfidentiality in Medicine A Decrepit Conceptrdquo pp 1518ndash21 from New England Journal of Medicine 307 24 (December 1982) Copyright copy 1982 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

69 Christian Saumlfken and Andreas Frewer ldquoThe Duty to Warn and Clinical Ethics Legal and Ethical Aspects of Confidentiality and HIVAIDSrdquo pp 313ndash326 from HEC Forum 19 4 (2007) With kind permission from Springer Science+Business Media

70 Immanuel Kant ldquoOn a Supposed Right to Lie from Altruistic Motivesrdquo pp 361ndash3 from Critique of Practical Reason and Other Works on the Theory of Ethics 6th edition trans T K Abbott London 1909 This essay was first published in a Berlin periodical in 1797

71 Joseph Collins ldquoShould Doctors Tell the Truthrdquo pp 320ndash6 from Harperrsquos Monthly Magazine 155 (August 1927) Copyright copy 1927 Harperrsquos Magazine All rights reserved Reproduced from the August issue by special permission

72 Roger Higgs ldquoOn Telling Patients the Truthrdquo pp 186ndash202 and 232ndash3 from Michael Lockwood (ed) Moral Dilemmas in Modern Medicine Oxford Oxford University Press 1985 By permission of Oxford University Press

73 John Stuart Mill ldquoOn Libertyrdquo first published in 1859

74 Justice Benjamin N Cardozo Judgment from Schloendorff v New York Hospital (1914) p 526 from Jay Katz (ed) Experimentation with Human Beings The Authority of the Investigator Subject Professions and State in the Human Experimentation Process New York Russell Sage Foundation 1972 Reproduced with permission of Russell Sage Foundation

75 Tom L Beauchamp ldquoInformed Consent Its History Meaning and Present Challengesrdquo pp 515ndash23 from Cambridge Quarterly of Health Care Ethics 20 4 (2011) copy Royal Institute of Philosophy published by Cambridge University Press Reproduced with permission from Cambridge University Press and T Beauchamp

76 Ruth Macklin ldquoThe DoctorndashPatient Relationshyship in Different Culturesrdquo pp 86ndash107 from

Against Relativism Cultural Diversity and the Search of Ethical Universals in Medicine copy 1999 by Oxford University Press Inc By permission of Oxford University Press USA

77 Carl Elliott ldquoAmputees by Choicerdquo pp 208ndash10 210ndash15 219ndash23 227ndash31 234ndash6 323ndash6 from Better Than Well American Medicine Meets the American Dream New York and London WW Norton 2003 Copyright copy 2003 by Carl Elliott Used by permission of W W Norton amp Company Inc

78 Julian Savulescu ldquoRational Desires and the Limishytation of Life‐Sustaining Treatmentrdquo pp 191ndash 222 from Bioethics 8 3 (1994) Reproduced with permission from John Wiley amp Sons

79 Shlomo Cohen ldquoThe Nocebo Effect of Informed Consentrdquo pp 147ndash54 from Bioethics 28 3 (2014) Reproduced with permission from John Wiley amp Sons

80 Sarah E Dock ldquoThe Relation of the Nurse to the Doctor and the Doctor to the Nurserdquo p 394 (extract) from The American Journal of Nursing 17 5 (1917)

81 Lisa H Newton ldquoIn Defense of the Traditional Nurserdquo pp 348ndash54 from Nursing Outlook 29 6 (1981) Copyright Elsevier 1981

82 Sarah Breier ldquoPatient Autonomy and Medical Paternity Can Nurses Help Doctors to Listen to Patientsrdquo pp 510ndash21 from Nursing Ethics 8 6 (2001) Reproduced with permission from Sage and S Breier

83 Carol Pavlish Anita Ho and Ann‐Marie Rounkle ldquoHealth and Human Rights Advocacy Perspectives from a Rwandan Refugee Camprdquo pp 538ndash49 from Nursing Ethics 19 4 (2012) Copyright copy 2012 by SAGE Publications Reprinted by Permission of SAGE

84 Jonathan D Moreno ldquoNeuroethics An Agenda for Neuroscience and Societyrdquo pp 149ndash53 from Nature Reviews 4 (February 2003)Reprinted by permission from Macmillan Publishers Ltd

85 Sally Adee ldquoHow Electrical Brain Stimulation Can Change the Way We Thinkrdquo The Week March 30 2012

86 Neil Levy ldquoNeuroethics Ethics and the Sciences of the Mindrdquo pp 69ndash74 (extract) from Philosophy

Acknowledgments xvii

Compass 4 10 (2009) pp 69ndash81 Reproduced with permission from John Wiley amp Sons

87 Adam Kolber ldquoFreedom of Memory Todayrdquo pp 145ndash8 from Neuroethics 1 (2008) With kind permission from Springer Science+Business Media

88 Henry Greely and Colleagues ldquoTowards Responsible Use of Cognitive‐Enhancing Drugs

by the Healthyrdquo pp 702ndash5 from Nature 456 (December 11 2008) Reprinted by permission from Macmillan Publishers Ltd

89 Julian Savulescu and Anders Sandberg ldquoEngineering LoverdquoldquoLove Machine Engineering Lifelong Romancerdquo pp 28ndash9 from New Scientist 2864 copy 2012 Reed Business Information ndash UK All rights reserved Distributed by Tribune Content Agency

Bioethics An Anthology Third Edition Edited by Helga Kuhse Udo Schuumlklenk and Peter Singer copy 2016 John Wiley amp Sons Inc Published 2016 by John Wiley amp Sons Inc

Introduction

The term ldquobioethicsrdquo was coined by Van Rensselaer Potter who used it to describe his proposal that we need an ethic that can incorporate our obligations not just to other humans but to the biosphere as a whole1 Although the term is still occasionally used in this sense of an ecological ethic it is now much more commonly used in the narrower sense of the study of ethical issues arising from the biological and medical sciences So understood bioethics has become a specialized although interdisciplinary area of study The essays included in this book give an indication of the range of issues which fall within its scope ndash but it is only an indication There are many other issues that we simply have not had the space to cover

Bioethics can be seen as a branch of ethics or more specifically of applied ethics For this reason some understanding of the nature of ethics is an essential preliminary to any serious study of bioethics The remainder of this introduction will seek to provide that understanding

One question about the nature of ethics is especially relevant to bioethics to what extent is reasoning or argument possible in ethics Many people assume without much thought that ethics is subjective The subjectivist holds that what ethical view we take is a matter of opinion or taste that is not amenable to argument But if ethics were a matter of taste why would we even attempt to argue about it If Helen says ldquoI like my coffee sweetenedrdquo whereas Paul says

ldquoI like my coffee unsweetenedrdquo there is not much point in Helen and Paul arguing about it The two statements do not contradict each other They can both be true But if Helen says ldquoDoctors should never assist their patients to dierdquo whereas Paul says ldquoSometimes doctors should assist their patients to dierdquo then Helen and Paul are disagreeing and there does seem to be a point in their trying to argue about the issue of physician‐assisted suicide

It seems clear that there is some scope for argument in ethics If I say ldquoIt is always wrong to kill a human beingrdquo and ldquoAbortion is not always wrongrdquo then I am committed to denying that abortion kills a human being Otherwise I have contradicted myself and in doing so I have not stated a coherent position at all So consistency at least is a requirement of any defensible ethical position and thus sets a limit to the subjectivity of ethical judgments The requirement of factual accuracy sets another limit In discussing issues in bioethics the facts are often complex But we cannot reach the right ethical decisions unless we are well‐informed about the relevant facts In this respect ethical decisions are unlike decisions of taste We can enjoy a taste without knowing what we are eating but if we assume that it is wrong to resuscitate a terminally ill patient against her wishes then we can-not know whether an instance of resuscitation was morally right or wrong without knowing something about the patientrsquos prognosis and whether the patient

2 introduction

has expressed any wishes about being resuscitated In that sense there is no equivalent in ethics to the immediacy of taste

Ethical relativism sometimes also known as cul-tural relativism is one step away from ethical sub-jectivism but it also severely limits the scope of ethical argument The ethical relativist holds that it is not individual attitudes that determine what is right or wrong but the attitudes of the culture in which one lives Herodotus tells how Darius King of Persia summoned the Greeks from the western shores of his kingdom before him and asked them how much he would have to pay them to eat their fathersrsquo dead bodies They were horrified by the idea and said they would not do it for any amount of money for it was their custom to cremate their dead Then Darius called upon Indians from the eastern frontiers of his kingdom and asked them what would make them willing to burn their fathersrsquo bodies They cried out and asked the King to refrain from mentioning so shocking an act Herodotus comments that each nation thinks its own customs best From here it is only a short step to the view that there can be no objective right or wrong beyond the bounds of onersquos own culture This view found increased support in the nine-teenth century as Western anthropologists came to know many different cultures and were impressed by ethical views very different from those that were standardly taken for granted in European society As a defense against the automatic assumption that Western morality is superior and should be imposed on ldquosavagesrdquo many anthropologists argued that since morality is relative to culture no culture can have any basis for regarding its morality as superior to any other culture

Although the motives with which anthropolo-gists put this view forward were admirable they may not have appreciated the implications of the position they were taking The ethical relativist maintains that a statement like ldquoIt is good to enslave people from another tribe if they are captured in warrdquo means simply ldquoIn my society the custom is to enslave people from another tribe if they are cap-tured in warrdquo Hence if one member of the society were to question whether it really was good to enslave people in these circumstances she could be

answered simply by demonstrating that this was indeed the custom ndash for example by showing that for many generations it had been done after every war in which prisoners were captured Thus there is no way for moral reformers to say that an accepted custom is wrong ndash ldquowrongrdquo just means ldquoin accord-ance with an accepted customrdquo

On the other hand when people from two different cultures disagree about an ethical issue then according to the ethical relativist there can be no resolution of the disagreement Indeed strictly there is no disagree-ment If the apparent dispute were over the issue just mentioned then one person would be saying ldquoIn my country it is the custom to enslave people from another tribe if they are captured in warrdquo and the other person would be saying ldquoIn my country it is not the custom to allow one human being to enslave anotherrdquo This is no more a disagreement than such statements as ldquoIn my country people greet each other by rubbing nosesrdquo and ldquoIn my country people greet each other by shaking handsrdquo If ethical relativism is true then it is impossible to say that one culture is right and the other is wrong Bearing in mind that some cultures have practiced slavery or the burning of widows on the funeral pyre of their husbands this is hard to accept

A more promising alternative to both ethical subjectivism and cultural relativism is universal pre-scriptivism an approach to ethics developed by the Oxford philosopher R M Hare Hare argues that the distinctive property of ethical judgments is that they are universalizable In saying this he means that if I make an ethical judgment I must be prepared to state it in universal terms and apply it to all relevantly similar situations By ldquouniversal termsrdquo Hare means those terms that do not refer to a particular individual Thus a proper name cannot be a universal term If for example I were to say ldquoEveryone should do what is in the interests of Mick Jaggerrdquo I would not be making a universal judgment because I have used a proper name The same would be true if I were to say that everyone must do what is in my interests because the personal pronoun ldquomyrdquo is here used to refer to a particular individual myself

It might seem that ruling out particular terms in this way does not take us very far After all one can always describe oneself in universal terms Perhaps

Introduction 3

I canrsquot say that everyone should do what is in my interests but I could say that everyone must do whatever is in the interests of people who hellip and then give a minutely detailed description of myself including the precise location of all my freckles The effect would be the same as saying that everyone should do what is in my interests because there would be no one except me who matches that description But Hare meets this problem very effectively by saying that to prescribe an ethical judgment universally means being prepared to pre-scribe it for all possible circumstances including hypothetical ones So if I were to say that everyone should do what is in the interests of a person with a particular pattern of freckles I must be prepared to prescribe that in the hypothetical situation in which I do not have this pattern of freckles but someone else does I should do what is in the interests of that person Now of course I may say that I should do that since I am confident that I shall never be in such a situation but this simply means that I am being dishonest I am not genuinely prescribing the principle universally

The effect of saying that an ethical judgment must be universalizable for hypothetical as well as actual circumstances is that whenever I make an ethical judgment I can be challenged to put myself in the position of the parties affected and see if I would still be able to accept that judgment Suppose for example that I own a small factory and the cheapest way for me to get rid of some waste is to pour it into a nearby river I do not take water from this river but I know that some villagers living downstream do and the waste may make them ill The requirement that ethical judgments should be universalizable will make it difficult for me to justify my conduct because if I imagine myself in the hypothetical situation of being one of the villagers rather than the factory‐owner I would not accept that the profits of the factory‐owner should outweigh the risk of adverse effects on my health and that of my children In this way Harersquos approach requires us to take into account the interests and preferences of all others affected by our actions Hence it allows for an element of reasoning in ethical deliberation

Since the rightness or wrongness of our actions will on this view depend on the way in which they

affect others Harersquos universal prescriptivism leads to a form of consequentialism ndash that is the view that the rightness of an action depends on its consequences The best‐known form of consequentialism is the clas-sical utilitarianism developed in the late eighteenth century by Jeremy Bentham and popularized in the nineteenth century by John Stuart Mill They held that an action is right if it leads to a greater surplus of happiness over misery than any possible alternative and wrong if it does not By ldquogreater surplus of happinessrdquo the classical utilitarians had in mind the idea of adding up all the pleasure or happiness that resulted from the action and subtracting from that total all the pain or misery to which the action gave rise Naturally in some circumstances it might be possible only to reduce misery and then the right action should be understood as the one that will result in less misery than any possible alternative

The utilitarian view is striking in many ways It puts forward a single principle that it claims can provide the right answer to all ethical dilemmas if only we can predict what the consequences of our actions will be It takes ethics out of the mysterious realm of duties and rules and bases ethical decisions on something that almost everyone understands and values Moreover utilitarianismrsquos single principle is applied universally without fear or favor Bentham said ldquoEach to count for one and none for more than onerdquo by which he meant that the happiness of a com-mon tramp counted for as much as that of a noble and the happiness of an African was no less important than that of a European

Many contemporary consequentialists agree with Bentham to the extent that they think the rightness or wrongness of an action must depend on its conse-quences but they have abandoned the idea that m aximizing net happiness is the ultimate goal Instead they argue that we should seek to bring about w hatever will satisfy the greatest number of desires or preference This variation which is known as ldquop reference utilitarianismrdquo does not regard anything as good except in so far as it is wanted or desired More intense or strongly held preferences would get more weight than weak preferences

Consequentialism offers one important answer to the question of how we should decide what is right and what is wrong but many ethicists reject it The

4 introduction

denial of this view was dramatically presented by Dostoevsky in The Karamazov Brothers

imagine that you are charged with building the edifice of human destiny the ultimate aim of which is to bring people happiness to give them peace and contentment at last but that in order to achieve this it is essential and unavoidable to torture just one little speck of creation that same little child beating her chest with her little fists and imagine that this edifice has to be erected on her unexpiated tears Would you agree to be the architect under those conditions Tell me honestly2

The passage suggests that some things are always wrong no matter what their consequences This has for most of Western history been the prevailing approach to morality at least at the level of what has been officially taught and approved by the institutions of Church and State The ten commandments of the Hebrew scriptures served as a model for much of the Christian era and the Roman Catholic Church built up an elaborate system of morality based on rules to which no exceptions were allowed

Another example of an ethic of rules is that of Immanuel Kant Kantrsquos ethic is based on his ldquocategori-cal imperativerdquo which he states in several distinct for-mulations One is that we must always act so that we can will the maxim of our action to be a universal law This can be interpreted as a form of Harersquos idea of universalizability which we have already encountered Another is that we must always treat other people as ends never as means While these formulations of the categorical imperative might be applied in various ways in Kantrsquos hands they lead to inviolable rules for example against making promises that we do not intend to keep Kant also thought that it was always wrong to tell a lie In response to a critic who sug-gested that this rule has exceptions Kant said that it would be wrong to lie even if someone had taken refuge in your house and a person seeking to murder him came to your door and asked if you knew where he was Modern Kantians often reject this hard-line approach to rules and claim that Kantrsquos categorical imperative did not require him to hold so strictly to the rule against lying

How would a consequentialist ndash for example a classical utilitarian ndash answer Dostoevskyrsquos challenge If answering honestly ndash and if one really could be certain

that this was a sure way and the only way of bringing lasting happiness to all the people of the world ndash utilitarians would have to say yes they would accept the task of being the architect of the happiness of the world at the cost of the childrsquos unexpiated tears For they would point out that the suffering of that child wholly undeserved as it is will be repeated a million‐fold over the next century for other children just as innocent who are victims of starvation disease and brutality So if this one child must be sacrificed to stop all this suffering then terrible as it is the child must be sacrificed

Fantasy apart there can be no architect of the hap-piness of the world The world is too big and complex a place for that But we may attempt to bring about less suffering and more happiness or satisfaction of preferences for people or sentient beings in specific places and circumstances Alternatively we might fol-low a set of principles or rules ndash which could be of varying degrees of rigidity or flexibility Where would such rules come from Kant tried to deduce them from his categorical imperative which in turn he had reached by insisting that the moral law must be based on reason alone without any content from our wants or desires But the problem with trying to deduce morality from reason alone has always been that it becomes an empty formalism that cannot tell us what to do To make it practical it needs to have some addi-tional content and Kantrsquos own attempts to deduce rules of conduct from his categorical imperative are unconvincing

Others following Aristotle have tried to draw on human nature as a source of moral rules What is good they say is what is natural to human beings They then contend that it is natural and right for us to seek certain goods such as knowledge friendship health love and procreation and unnatural and wrong for us to act contrary to these goods This ldquonatural lawrdquo ethic is open to criticism on several points The word ldquonaturalrdquo can be used both descriptively and evalua-tively and the two senses are often mixed together so that value judgments may be smuggled in under the guise of a description The picture of human nature presented by proponents of natural law ethics usually selects only those characteristics of our nature that the proponent considers desirable The fact that our species especially its male members frequently go to war and

Introduction 5

are also prone to commit individual acts of violence against others is no doubt just as much part of our nature as our desire for knowledge but no natural law theorist therefore views these activities as good More generally natural law theory has its origins in an Aristotelian idea of the cosmos in which everything has a goal or ldquoendrdquo which can be deduced from its nature The ldquoendrdquo of a knife is to cut the assumption is that human beings also have an ldquoendrdquo and we will flourish when we live in accordance with the end for which we are suited But this is a pre‐Darwinian view of nature Since Darwin we know that we do not exist for any purpose but are the result of natural selection operating on random mutations over millions of years Hence there is no reason to believe that living accord-ing to nature will produce a harmonious society let alone the best possible state of affairs for human beings

Another way in which it has been claimed that we can come to know what moral principles or rules we should follow is through our intuition In practice this usually means that we adopt conven-tionally accepted moral principles or rules perhaps with some adjustments in order to avoid inconsist-ency or arbitrariness On this view a moral theory should like a scientific theory try to match the data and the data that a moral theory must match is p rovided by our moral intuitions As in science if a plausible theory matches most but not all of the data then the anomalous data might be rejected on the grounds that it is more likely that there was an error in the procedures for gathering that particular set of data than that the theory as a whole is mis-taken But ultimately the test of a theory is its ability to explain the data The problem with applying this model of scientific justification to ethics is that the ldquodatardquo of our moral intuitions is unreliable not just at one or two specific points but as a whole Here the facts that cultural relativists draw upon are rele-vant (even if they do not establish that cultural rela-tivism is the correct response to it) Since we know that our intuitions are strongly influenced by such things as culture and religion they are ill‐suited to serve as the fixed points against which an ethical theory must be tested Even where there is cross‐cultural agreement there may be some aspects of our intuitions on which all cultures unjustifiably favor our own interests over those of others For

example simply because we are all human beings we may have a systematic bias that leads us to give an unjustifiably low moral status to nonhuman a nimals Or because in virtually all known human societies men have taken a greater leadership role than women the moral intuitions of all societies may not adequately reflect the interests of females

Some philosophers think that it is a mistake to base ethics on principles or rules Instead they focus on what it is to be a good person ndash or in the case of the problems with which this book is concerned perhaps on what it is to be a good nurse or doctor or researcher They seek to describe the virtues that a good person or a good member of the relevant profession should possess Moral education then consists of teaching these virtues and discussing how a virtuous person would act in specific situations The question is how-ever whether we can have a notion of what a virtuous person would do in a specific situation without making a prior decision about what it is right to do After all in any particular moral dilemma different virtues may be applicable and even a particular virtue will not always give unequivocal guidance For instance if a terminally ill patient repeatedly asks a nurse or doctor for assistance in dying what response best exemplifies the virtues of a healthcare professional There seems no answer to this question short of an inquiry into whether it is right or wrong to help a patient in such circumstances to die But in that case we seem bound in the end to come back to discuss-ing such issues as whether it is right to follow moral rules or principles or to do what will have the best consequences

In the late twentieth century some feminists offered new criticisms of conventional thought about ethics They argued that the approaches to ethics taken by the influential philosophers of the past ndash all of whom have been male ndash give too much emphasis to abstract principles and the role of reason and give too little attention to personal relationships and the part played by emotion One outcome of these criticisms has been the development of an ldquoethic of carerdquo which is not so much a single ethical theory as a cluster of ways of looking at ethics which put an attitude of c aring for others at the center and seek to avoid r eliance on abstract ethical principles The ethic of care has seemed especially applicable to the work of those

6 introduction

involved in direct patient care and has recently been taken up by a number of nursing theorists as offering a more suitable alternative to other ideas of ethics Not all feminists however support this development Some worry that the adoption of a ldquocarerdquo approach by nurses may reflect and even reinforce stereotypes of women as more emotional and less rational than men They also fear that it could lead to women continuing to carry a disproportionate burden of caring for others to the exclusion of adequately caring for themselves

In this discussion of ethics we have not mentioned anything about religion This may seem odd in view of the close connection that has often been made between religion and ethics but it reflects our belief that despite this historical connection ethics and reli-gion are fundamentally independent Logically ethics is prior to religion If religious believers wish to say that a deity is good or praise her or his creation or deeds they must have a notion of goodness that is independent of their conception of the deity and what she or he does Otherwise they will be saying that the deity is good and when asked what they mean by ldquogoodrdquo they will have to refer back to the deity saying perhaps that ldquogoodrdquo means ldquoin accord-ance with the wishes of the deityrdquo In that case sen-tences such as ldquoGod is goodrdquo would be a meaningless tautology ldquoGod is goodrdquo could mean no more than ldquoGod is in accordance with Godrsquos wishesrdquo As we have already seen there are ideas of what it is for something to be ldquogoodrdquo that are not rooted in any religious belief While religions typically encourage or instruct their followers to obey a particular ethical code it is obvious that others who do not follow any religion can also think and act ethically

To say that ethics is independent of religion is not to deny that theologians or other religious believers may have a role to play in bioethics Religious traditions often have long histories of dealing with ethical dilem-mas and the accumulation of wisdom and experience that they represent can give us valuable insights into particular problems But these insights should be subject to criticism in the way that any other proposals would be If in the end we accept them it is because we have judged them sound not because they are the utterances of a pope a rabbi a mullah or a holy person

Ethics is also independent of the law in the sense that the rightness or wrongness of an act cannot be

settled by its legality or illegality Whether an act is legal or illegal may often be relevant to whether it is right or wrong because it is arguably wrong to break the law other things being equal Many people have thought that this is especially so in a democracy in which everyone has a say in making the law Another reason why the fact that an act is illegal may be a rea-son against doing it is that the legality of an act may affect the consequences that are likely to flow from it If active voluntary euthanasia is illegal then doctors who practice it risk going to jail which will cause them and their families to suffer and also mean that they will no longer be able to help other patients This can be a powerful reason for not practicing voluntary euthanasia when it is against the law but if there is only a very small chance of the offense becoming known or being proved then the weight of this con-sequentialist reason against breaking the law is reduced accordingly Whether we have an ethical obligation to obey the law and if so how much weight should be given to it is itself an issue for ethical argument

Though ethics is independent of the law in the sense just specified laws are subject to evaluation from an ethical perspective Many debates in bioethics focus on questions about what practices should be allowed ndash for example should we allow research on stem cells taken from human embryos sex selection or cloning ndash and committees set up to advise on the ethical social and legal aspects of these questions often recommend legislation to prohibit the activity in question or to allow it to be practiced under some form of regulation Discussing a question at the level of law and public policy however raises somewhat different considerations than a discussion of personal ethics because the consequences of adopting a public policy generally have much wider ramifications than the consequences of a personal choice That is why some healthcare professionals feel justified in assisting a terminally ill patient to die while at the same time opposing the legalization of physician‐assisted suicide Paradoxical as this position may appear ndash and it is certainly open to criticism ndash it is not straightforwardly inconsistent

Naturally many of the essays we have selected reflect the times in which they were written Since bioethics often comments on developments in fast‐moving

Introduction 7

areas of medicine and the biological sciences the factual content of articles in bioethics can become obsolete quite rapidly In preparing this revised edition we have taken the opportunity to cover some new issues and to include some more recent writings We have for example included new mate-rial on genetic enhancement as well as on the use of embryonic human stem cells This edition of the anthology also includes new sections on ethical issues in public health and in the neurosciences Nevertheless an article that has dated in regard to its facts often makes ethical points that are still valid

or worth considering so we have not excluded older articles for this reason

Other articles are dated in a different way During the past few decades we have become more sensitive about the ways in which our language may exclude women or reflect our prejudices regarding race or sexuality We see no merit in trying to disguise past practices on such matters so we have not excluded otherwise valuable works in bioethics on these grounds If they are jar-ring to the modern reader that may be a salutary reminder of the extent to which we all are subject to the conventions and prejudices of our times

Notes

1 See Van Rensselaer Potter Bioethics Bridge to the Future (Englewood Cliffs NJ Prentice‐Hall 1971)

2 The Karamazov Brothers trans Ignat Avsey (Oxford Oxford University Press 1994) vol I part 2 bk 5 ch 4 First published in 1879

Abortion

Part I

Acknowledgments

The editor and publisher gratefully acknowledge the permission granted to reproduce the copyright material in this book

1 John Finnis ldquoAbortion and Health Care Ethicsrdquo pp 547ndash57 from Raanan Gillon (ed) Principles of Health Care Ethics Chichester John Wiley 1994 Reproduced with permission from John Wiley amp Sons

2 Michael Tooley ldquoAbortion and Infanticiderdquo pp 37ndash65 from Philosophy and Public Affairs 1 (1972) Reproduced with permission from John Wiley amp Sons

3 Judith Jarvis Thomson ldquoA Defense of Abortionrdquo pp 47ndash66 from Philosophy and Public Affairs 1 1 (1971) Reproduced with permission from John Wiley amp Sons

4 Don Marquis ldquoWhy Abortion Is Immoralrdquo Journal of Philosophy 86 4 (April 1989) 183ndash202

5 Gregory Pence ldquoMultiple Gestation and Damaged Babies Godrsquos Will or Human Choicerdquo This essay draws on ldquoThe McCaughey Septuplets Godrsquos Will or Human Choicerdquo pp 39ndash43 from Gregory Pence Brave New Bioethics Lanham MD Rowman amp Littlefield 2002 copy Gregory Pence 2002 Courtesy of G Pence

6 Dorothy A Greenfeld and Emre Seli ldquoAssisted Reproduction in Same Sex Couplesrdquo pp 289ndash301 from M V Sauer (ed) Principles of Oocyte and Embryo Donation Springer‐Verlag 2013 With kind permisshysion from Springer Science+Business Media

7 Derek Parfit ldquoRights Interests and Possible Peoplerdquo pp 369ndash75 from Samuel Gorovitz et al (eds) Moral

Problems in Medicine Englewood Cliffs NJ Prentice Hall 1976 Courtesy of D Parfit

8 Ruby Catsanos Wendy Rogers and Mianna Lotz ldquoThe Ethics of Uterus Transplantationrdquo pp 65ndash73 from Bioethics 27 2 (2013) Reproduced by permission of John Wiley amp Sons

9 Laura M Purdy ldquoGenetics and Reproductive Risk Can Having Children be Immoralrdquo pp 39ndash49 from Reproducing Persons Issues in Feminist Bioethics Ithaca NY Cornell University Press 1996 Reproduced with permission from Cornell University Press

10 Adrienne Asch ldquoPrenatal Diagnosis and Selective Abortion A Challenge to Practice and Policyrdquo pp 1649ndash57 from American Journal of Public Health 89 11 (1999) Reproduced with permisshysion from American Public Health Association

11 Ruth Chadwick and Mairi Levitt ldquoGenetic Technology A Threat to Deafnessrdquo pp 209ndash15 from Medicine Healthcare and Philosophy 1 (1998) With kind permission from Springer Science+ Business Media

12 The Ethics Committee of the American Society of Reproductive Medicine ldquoSex Selection and Preimplantation Genetic Diagnosisrdquo pp 595ndash8 from Fertility and Sterility 72 4 (October 1999) Reprinted with permission from Elsevier

13 Julian Savulescu and Edgar Dahl ldquoSex Selection and Preimplantation Diagnosis A Response to the Ethics Committee of the American Society of Reproductive Medicinerdquo pp 1879ndash80 from Human Reproduction 15 9 (2000) By permission of Oxford University Press

Acknowledgments xiii

14 John A Robertson Jeffrey P Kahn and John E Wagner ldquoConception to Obtain Hematopoietic Stem Cellsrdquo pp 34ndash40 from Hastings Center Report 32 3 (MayJune 2002) Reproduced with permission from John Wiley amp Sons

15 David King ldquoWhy We Should Not Permit Embryos to Be Selected as Tissue Donorsrdquo pp 13ndash16 from The Bulletin of Medical Ethics 190 (August 2003) Copyright copy RSM Press 2003 Reproduced by permission of SAGE Publications Ltd London Los Angeles New Delhi Singapore and Washington DC

16 Michael Tooley ldquoThe Moral Status of the Cloning of Humansrdquo pp 67ndash101 from James M Humber and Robert I Almeder (eds) Human Cloning Totowa NJ Humana Press 1998 With kind permission from Springer Science+Business Media

17 Jonathan Glover ldquoQuestions about Some Uses of Genetic Engineeringrdquo pp 25ndash33 33ndash6 42ndash3 and 45ndash53 from What Sort of People Should There Be Harmondsworth Penguin Books 1984 Reproshyduced by permission of Penguin Books Ltd

18 David B Resnik ldquoThe Moral Significance of the TherapyndashEnhancement Distinction in Human Geneticsrdquo pp 365ndash77 from Cambridge Quarterly of Healthcare Ethics 9 3 (Summer 2000) copy Cambridge University Press Reproduced with permission

19 Ainsley Newson and Robert Williamson ldquoShould We Undertake Genetic Research on Intelligencerdquo pp 327ndash42 from Bioethics 13 34 (1999) Reproduced with permission from John Wiley amp Sons

20 Nick Bostrom ldquoIn Defense of Posthuman Dignityrdquo pp 202ndash14 from Bioethics 19 3 (2005) Reproduced with permission from John Wiley amp Sons

21 Jonathan Glover ldquoThe Sanctity of Liferdquo pp 39ndash59 from Causing Death and Lives London Pelican 1977 Reproduced by permission of Penguin Books Ltd

22 Sacred Congregation for the Doctrine of the Faith ldquoDeclaration on Euthanasiardquo Vatican City 1980

23 Germain Grisez and Joseph M Boyle Jr ldquoThe Morality of Killing A Traditional Viewrdquo

pp 381ndash419 from Life and Death with Liberty and Justice A Contribution to the Euthanasia Debate Notre Dame IN University of Notre Dame Press 1971

24 James Rachels ldquoActive and Passive Euthanasiardquo pp 78ndash80 from New England Journal of Medicine 292 (1975) Copyright copy 1975 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

25 Winston Nesbitt ldquoIs Killing No Worse Than Letting Dierdquo pp 101ndash5 from Journal of Applied Philosophy 12 1 (1995) Reproduced with permission from John Wiley amp Sons

26 Helga Kuhse ldquoWhy Killing Is Not Always Worse ndash and Sometimes Better ndash Than Letting Dierdquo pp 371ndash4 from Cambridge Quarterly of Healthcare 7 4 (1998) copy Cambridge University Press Reproduced with permission

27 Franklin G Miller Robert D Truog and Dan W Brock ldquoMoral Fictions and Medical Ethicsrdquo pp 453ndash60 from Bioethics 24 9 (2010) Reproduced with permission from John Wiley amp Sons

28 Neil Campbell ldquoWhen Care Cannot Cure Medical Problems in Seriously Ill Babiesrdquo pp 327ndash44 from F K Beller and R F Weir (eds) The Beginning of Human Life Dordrecht Kluwer Academic Publishers 1994 With kind pershymission from Springer Science+Business Media

29 R M Hare ldquoThe Abnormal Child Moral Dilemmas of Doctors and Parentsrdquo Reprinted in Essays on Bioethics Oxford Clarendon Press 1993 pp185ndash91 Courtesy of the Estate of R M Hare

30 Alison Davis ldquoRight to Life of Handicappedrdquo p 181 from Journal of Medical Ethics 9 (1983) Reproduced with permission from BMJ Publishing Group

31 Christine Overall ldquoConjoined Twins Embodied Personhood and Surgical Separationrdquo pp 69ndash84 from L Tessman (ed) Feminist Ethics and Social and Political Philosophy Theorizing the Non‐Ideal Springer 2009 With kind permission from Springer Science+Business Media

32 Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death ldquolsquoA Definition of Irreversible Comarsquo Report to Examine the Definition of Brain

xiv acknowledgments

Deathrdquo pp 85ndash8 from Journal of the American Medical Association 205 6 (August 1968) Copyright copy 1968 American Medical Association All rights reserved

33 Ari Joffe ldquoAre Recent Defences of the Brain Death Concept Adequaterdquo pp 47ndash53 from Bioethics 24 2 (February 2010) Reproduced with permission from John Wiley amp Sons

34 Peter Singer ldquoIs the Sanctity of Life Ethic Terminally Illrdquo pp 307ndash43 from Bioethics 9 34 (1995) Reproduced with permission from John Wiley amp Sons

35 Ronald Dworkin ldquoLife Past Reasonrdquo pp 218ndash29 from Lifersquos Dominion An Argument about Abortion Euthanasia and Individual Freedom New York Knopf 1993 Copyright copy 1993 by Ronald Dworkin Used by permission of Alfred A Knopf an imprint of the Knopf Doubleday Publishing Group a division of Random House LLC All rights reserved

36 Rebecca Dresser ldquoDworkin on Dementia Elegant Theory Questionable Policyrdquo pp 32ndash8 from Hastings Center Report 25 6 (NovemberDecember 1995) Reproduced with permission from John Wiley amp Sons

37 Chris Hill ldquoThe Noterdquo pp 9ndash17 from Helga Kuhse (ed) Willing to Listen Wanting to Die Ringwood Australia Penguin Books 1994

38 Daniel Callahan ldquoWhen Self‐Determination Runs Amokrdquo pp 52ndash5 from Hastings Center Report 22 2 (MarchApril 1992) Reproduced with permission from John Wiley amp Sons

39 John Lachs ldquoWhen Abstract Moralizing Runs Amokrdquo pp 10ndash13 from The Journal of Clinical Ethics 5 1 (Spring 1994) Copyright JCE

40 Bregje D Onwuteaka‐Philipsen et al ldquoTrends in End‐Of‐Life Practices Before and After the Enactment of the Euthanasia Law in the Netherlands from 1990 to 2010 A Repeated Cross‐Sectional Surveyrdquo pp 908ndash15 from The Lancet 380 9845 (2012) Reprinted from The Lancet with permission from Elsevier

41 Bernard Lo ldquoEuthanasia in the Netherlands What Lessons for Elsewhererdquo pp 869ndash70 from The Lancet 380 (September 8 2012) Copyright 2012 Reprinted from The Lancet with permisshysion from Elsevier

42 Paul T Menzel ldquoRescuing Lives Canrsquot We Countrdquo pp 22ndash3 from Hastings Center Report 24 1 (1994) Reproduced with permission from John Wiley amp Sons

43 Alvin H Moss and Mark Siegler ldquoShould Alcoholics Compete Equally for Liver Transshyplantationrdquo pp 1295ndash8 from Journal of the American Medical Association 265 10 (1991) Copyright copy 1991 American Medical Association All rights reserved

44 John Harris ldquoThe Value of Liferdquo pp 87ndash102 from The Value of Life London Routledge 1985 Copyright 1985 Routledge Reproduced by permission of Taylor amp Francis Books UK

45 Nick Beckstead and Toby Ord ldquoBubbles under the Wallpaper Healthcare Rationing and Disshycriminationrdquo a paper presented to the confershyence ldquoValuing Livesrdquo New York University March 5 2011 copy Nick Beckstead and Toby Ord reprinted by permission of the authors This paper is published here for the first time but draws on Nick Beckstead and Toby Ord ldquoRationing and Rationality The Cost of Avoiding Discriminationrdquo in N Eyal et al (eds) Inequalities in Health Concepts Measures and Ethics Oxford Oxford University Press 2013 pp 232ndash9 By permission of Oxford University Press

46 Eike‐Henner W Kluge ldquoOrgan Donation and Retrieval Whose Body Is It Anywayrdquo copy 1999 by Eike‐Henner W Kluge

47 Janet Radcliffe‐Richards et al ldquoThe Case for Allowing Kidney Salesrdquo pp 1950ndash2 from The Lancet 351 9120 (June 27 1998) Reprinted with permission from Elsevier

48 Debra Satz ldquoEthical Issues in the Supply and Demand of Human Kidneysrdquo pp 189ndash206 from Why Some Things Should Not Be for Sale The Moral Limits of Markets New York Oxford University Press 2010 ch 9 based on an article from Proceedings of the Aristotelian Society Reprinted by courtesy of the Editor of Proceedings of the Aristotelian Society copy 2010

49 John Harris ldquoThe Survival Lotteryrdquo pp 81ndash7 from Philosophy 50 (1975) copy Royal Institute of Philosophy published by Cambridge University Press Reproduced with permission

Acknowledgments xv

50 Henry K Beecher ldquoEthics and Clinical Researchrdquo pp 1354ndash60 from New England Journal of Medicine 274 24 (June 1966) Copyright copy 1996 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

51 Benjamin Freedman ldquoEquipoise and the Ethics of Clinical Researchrdquo pp 141ndash5 from New England Journal of Medicine 317 3 (July 1987) Copyright copy 1987 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

52 Samuel Hellman ldquoThe Patient and the Public Goodrdquo pp 400ndash2 from Nature Medicine 1 5 (1995) Reprinted by permission from Macmillan Publishers Ltd

53 John Harris ldquoScientific Research Is a Moral Dutyrdquo pp 242ndash8 from Journal of Medical Ethics 31 4 (2005) Reproduced with permission from BMJ Publishing Group

54 Sandra Shapshay and Kenneth D Pimple ldquoParticipation in Research Is an Imperfect Moral Duty A Response to John Harrisrdquo pp 414ndash17 from Journal of Medical Ethics 33 (2007) Reproduced with permission from BMJ Publishing Group

55 Peter Lurie and Sidney M Wolfe ldquoUnethical Trials of Interventions to Reduce Perinatal Transmission of the Human Immunodeficiency Virus in Developing Countriesrdquo pp 853ndash6 from New England Journal of Medicine 337 12 (September 1997) Copyright copy 1997 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

56 Danstan Bageda and Philippa Musoke‐Mudido ldquoWersquore Trying to Help Our Sickest People Not Exploit Themrdquo from The Washington Post September 28 1997 copy 1997 Washington Post Company All rights reserved Used by permisshysion and protected by the Copyright Laws of the United States The printing copying redistribushytion or retransmission of this Content without express written permission is prohibited

57 Leah Belsky and Henry S Richardson ldquoMedical Researchersrsquo Ancillary Clinical Care Respon sibilitiesrdquo pp 1494ndash6 from British

Medical Journal 328 (June 19 2004) Reproduced with permission from BMJ Publishing Group

58 George W Bush ldquoPresident Discusses Stem Cell Researchrdquo Office of the Press Secretary White House August 9 2001

59 Jeff McMahan ldquoKilling Embryos for Stem Cell Researchrdquo pp 170ndash89 from Metaphilosophy 38 23 (2007) Reproduced with permission from John Wiley amp Sons

60 Immanuel Kant ldquoDuties towards Animalsrdquo pp 239ndash41 from Lectures on Ethics trans Louis Infield London Methuen 1930 Copyright 1930 Methuen reproduced by permission of Taylor amp Francis Books UK

61 Jeremy Bentham ldquoA Utilitarian Viewrdquo section XVIII IV from An Introduction to the Principles of Morals and Legislation First published c1820

62 Peter Singer ldquoAll Animals are Equalrdquo pp 103ndash16 from Philosophic Exchange 1 5 (1974) Center for Philosophic Exchange State University of New York Brockford NY 1974

63 R G Frey and Sir William Paton ldquoVivisection Morals and Medicine An Exchangerdquo pp 94ndash7 and 102ndash4 from Journal of Medical Ethics 9 (1983) Reproduced with permission from BMJ Publishing Group

64 Michael J Selgelid ldquoEthics and Infectious Diseaserdquo pp 272ndash89 from Bioethics 19 3 (2005) Reproduced with permission from John Wiley amp Sons

65 Udo Schuumlklenk and Anita Kleinsmidt ldquoRethinking Mandatory HIV Testing during Pregnancy in Areas with High HIV Prevalence Rates Ethical and Policy Issuesrdquo pp 1179ndash83 from American Journal of Public Health 97 7 (2007) Reproduced with permission from American Public Health Association

66 Russell Armstrong ldquoMandatory HIV Testing in Pregnancy Is There Ever a Timerdquo pp 1ndash10 from Developing World Bioethics 8 1 (2008) Reproduced with permission from John Wiley amp Sons

67 Jerome Amir Singh Ross Upshur and Nesri Padayatchi ldquoXDR‐TB in South Africa No Time for Denial or Complacencyrdquo PLoS Med 4 1 (2007) e50 doi101371journalpmed0040050 Copyright copy 2007 Singh et al

xvi acknowledgments

68 Mark Siegler ldquoConfidentiality in Medicine A Decrepit Conceptrdquo pp 1518ndash21 from New England Journal of Medicine 307 24 (December 1982) Copyright copy 1982 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

69 Christian Saumlfken and Andreas Frewer ldquoThe Duty to Warn and Clinical Ethics Legal and Ethical Aspects of Confidentiality and HIVAIDSrdquo pp 313ndash326 from HEC Forum 19 4 (2007) With kind permission from Springer Science+Business Media

70 Immanuel Kant ldquoOn a Supposed Right to Lie from Altruistic Motivesrdquo pp 361ndash3 from Critique of Practical Reason and Other Works on the Theory of Ethics 6th edition trans T K Abbott London 1909 This essay was first published in a Berlin periodical in 1797

71 Joseph Collins ldquoShould Doctors Tell the Truthrdquo pp 320ndash6 from Harperrsquos Monthly Magazine 155 (August 1927) Copyright copy 1927 Harperrsquos Magazine All rights reserved Reproduced from the August issue by special permission

72 Roger Higgs ldquoOn Telling Patients the Truthrdquo pp 186ndash202 and 232ndash3 from Michael Lockwood (ed) Moral Dilemmas in Modern Medicine Oxford Oxford University Press 1985 By permission of Oxford University Press

73 John Stuart Mill ldquoOn Libertyrdquo first published in 1859

74 Justice Benjamin N Cardozo Judgment from Schloendorff v New York Hospital (1914) p 526 from Jay Katz (ed) Experimentation with Human Beings The Authority of the Investigator Subject Professions and State in the Human Experimentation Process New York Russell Sage Foundation 1972 Reproduced with permission of Russell Sage Foundation

75 Tom L Beauchamp ldquoInformed Consent Its History Meaning and Present Challengesrdquo pp 515ndash23 from Cambridge Quarterly of Health Care Ethics 20 4 (2011) copy Royal Institute of Philosophy published by Cambridge University Press Reproduced with permission from Cambridge University Press and T Beauchamp

76 Ruth Macklin ldquoThe DoctorndashPatient Relationshyship in Different Culturesrdquo pp 86ndash107 from

Against Relativism Cultural Diversity and the Search of Ethical Universals in Medicine copy 1999 by Oxford University Press Inc By permission of Oxford University Press USA

77 Carl Elliott ldquoAmputees by Choicerdquo pp 208ndash10 210ndash15 219ndash23 227ndash31 234ndash6 323ndash6 from Better Than Well American Medicine Meets the American Dream New York and London WW Norton 2003 Copyright copy 2003 by Carl Elliott Used by permission of W W Norton amp Company Inc

78 Julian Savulescu ldquoRational Desires and the Limishytation of Life‐Sustaining Treatmentrdquo pp 191ndash 222 from Bioethics 8 3 (1994) Reproduced with permission from John Wiley amp Sons

79 Shlomo Cohen ldquoThe Nocebo Effect of Informed Consentrdquo pp 147ndash54 from Bioethics 28 3 (2014) Reproduced with permission from John Wiley amp Sons

80 Sarah E Dock ldquoThe Relation of the Nurse to the Doctor and the Doctor to the Nurserdquo p 394 (extract) from The American Journal of Nursing 17 5 (1917)

81 Lisa H Newton ldquoIn Defense of the Traditional Nurserdquo pp 348ndash54 from Nursing Outlook 29 6 (1981) Copyright Elsevier 1981

82 Sarah Breier ldquoPatient Autonomy and Medical Paternity Can Nurses Help Doctors to Listen to Patientsrdquo pp 510ndash21 from Nursing Ethics 8 6 (2001) Reproduced with permission from Sage and S Breier

83 Carol Pavlish Anita Ho and Ann‐Marie Rounkle ldquoHealth and Human Rights Advocacy Perspectives from a Rwandan Refugee Camprdquo pp 538ndash49 from Nursing Ethics 19 4 (2012) Copyright copy 2012 by SAGE Publications Reprinted by Permission of SAGE

84 Jonathan D Moreno ldquoNeuroethics An Agenda for Neuroscience and Societyrdquo pp 149ndash53 from Nature Reviews 4 (February 2003)Reprinted by permission from Macmillan Publishers Ltd

85 Sally Adee ldquoHow Electrical Brain Stimulation Can Change the Way We Thinkrdquo The Week March 30 2012

86 Neil Levy ldquoNeuroethics Ethics and the Sciences of the Mindrdquo pp 69ndash74 (extract) from Philosophy

Acknowledgments xvii

Compass 4 10 (2009) pp 69ndash81 Reproduced with permission from John Wiley amp Sons

87 Adam Kolber ldquoFreedom of Memory Todayrdquo pp 145ndash8 from Neuroethics 1 (2008) With kind permission from Springer Science+Business Media

88 Henry Greely and Colleagues ldquoTowards Responsible Use of Cognitive‐Enhancing Drugs

by the Healthyrdquo pp 702ndash5 from Nature 456 (December 11 2008) Reprinted by permission from Macmillan Publishers Ltd

89 Julian Savulescu and Anders Sandberg ldquoEngineering LoverdquoldquoLove Machine Engineering Lifelong Romancerdquo pp 28ndash9 from New Scientist 2864 copy 2012 Reed Business Information ndash UK All rights reserved Distributed by Tribune Content Agency

Bioethics An Anthology Third Edition Edited by Helga Kuhse Udo Schuumlklenk and Peter Singer copy 2016 John Wiley amp Sons Inc Published 2016 by John Wiley amp Sons Inc

Introduction

The term ldquobioethicsrdquo was coined by Van Rensselaer Potter who used it to describe his proposal that we need an ethic that can incorporate our obligations not just to other humans but to the biosphere as a whole1 Although the term is still occasionally used in this sense of an ecological ethic it is now much more commonly used in the narrower sense of the study of ethical issues arising from the biological and medical sciences So understood bioethics has become a specialized although interdisciplinary area of study The essays included in this book give an indication of the range of issues which fall within its scope ndash but it is only an indication There are many other issues that we simply have not had the space to cover

Bioethics can be seen as a branch of ethics or more specifically of applied ethics For this reason some understanding of the nature of ethics is an essential preliminary to any serious study of bioethics The remainder of this introduction will seek to provide that understanding

One question about the nature of ethics is especially relevant to bioethics to what extent is reasoning or argument possible in ethics Many people assume without much thought that ethics is subjective The subjectivist holds that what ethical view we take is a matter of opinion or taste that is not amenable to argument But if ethics were a matter of taste why would we even attempt to argue about it If Helen says ldquoI like my coffee sweetenedrdquo whereas Paul says

ldquoI like my coffee unsweetenedrdquo there is not much point in Helen and Paul arguing about it The two statements do not contradict each other They can both be true But if Helen says ldquoDoctors should never assist their patients to dierdquo whereas Paul says ldquoSometimes doctors should assist their patients to dierdquo then Helen and Paul are disagreeing and there does seem to be a point in their trying to argue about the issue of physician‐assisted suicide

It seems clear that there is some scope for argument in ethics If I say ldquoIt is always wrong to kill a human beingrdquo and ldquoAbortion is not always wrongrdquo then I am committed to denying that abortion kills a human being Otherwise I have contradicted myself and in doing so I have not stated a coherent position at all So consistency at least is a requirement of any defensible ethical position and thus sets a limit to the subjectivity of ethical judgments The requirement of factual accuracy sets another limit In discussing issues in bioethics the facts are often complex But we cannot reach the right ethical decisions unless we are well‐informed about the relevant facts In this respect ethical decisions are unlike decisions of taste We can enjoy a taste without knowing what we are eating but if we assume that it is wrong to resuscitate a terminally ill patient against her wishes then we can-not know whether an instance of resuscitation was morally right or wrong without knowing something about the patientrsquos prognosis and whether the patient

2 introduction

has expressed any wishes about being resuscitated In that sense there is no equivalent in ethics to the immediacy of taste

Ethical relativism sometimes also known as cul-tural relativism is one step away from ethical sub-jectivism but it also severely limits the scope of ethical argument The ethical relativist holds that it is not individual attitudes that determine what is right or wrong but the attitudes of the culture in which one lives Herodotus tells how Darius King of Persia summoned the Greeks from the western shores of his kingdom before him and asked them how much he would have to pay them to eat their fathersrsquo dead bodies They were horrified by the idea and said they would not do it for any amount of money for it was their custom to cremate their dead Then Darius called upon Indians from the eastern frontiers of his kingdom and asked them what would make them willing to burn their fathersrsquo bodies They cried out and asked the King to refrain from mentioning so shocking an act Herodotus comments that each nation thinks its own customs best From here it is only a short step to the view that there can be no objective right or wrong beyond the bounds of onersquos own culture This view found increased support in the nine-teenth century as Western anthropologists came to know many different cultures and were impressed by ethical views very different from those that were standardly taken for granted in European society As a defense against the automatic assumption that Western morality is superior and should be imposed on ldquosavagesrdquo many anthropologists argued that since morality is relative to culture no culture can have any basis for regarding its morality as superior to any other culture

Although the motives with which anthropolo-gists put this view forward were admirable they may not have appreciated the implications of the position they were taking The ethical relativist maintains that a statement like ldquoIt is good to enslave people from another tribe if they are captured in warrdquo means simply ldquoIn my society the custom is to enslave people from another tribe if they are cap-tured in warrdquo Hence if one member of the society were to question whether it really was good to enslave people in these circumstances she could be

answered simply by demonstrating that this was indeed the custom ndash for example by showing that for many generations it had been done after every war in which prisoners were captured Thus there is no way for moral reformers to say that an accepted custom is wrong ndash ldquowrongrdquo just means ldquoin accord-ance with an accepted customrdquo

On the other hand when people from two different cultures disagree about an ethical issue then according to the ethical relativist there can be no resolution of the disagreement Indeed strictly there is no disagree-ment If the apparent dispute were over the issue just mentioned then one person would be saying ldquoIn my country it is the custom to enslave people from another tribe if they are captured in warrdquo and the other person would be saying ldquoIn my country it is not the custom to allow one human being to enslave anotherrdquo This is no more a disagreement than such statements as ldquoIn my country people greet each other by rubbing nosesrdquo and ldquoIn my country people greet each other by shaking handsrdquo If ethical relativism is true then it is impossible to say that one culture is right and the other is wrong Bearing in mind that some cultures have practiced slavery or the burning of widows on the funeral pyre of their husbands this is hard to accept

A more promising alternative to both ethical subjectivism and cultural relativism is universal pre-scriptivism an approach to ethics developed by the Oxford philosopher R M Hare Hare argues that the distinctive property of ethical judgments is that they are universalizable In saying this he means that if I make an ethical judgment I must be prepared to state it in universal terms and apply it to all relevantly similar situations By ldquouniversal termsrdquo Hare means those terms that do not refer to a particular individual Thus a proper name cannot be a universal term If for example I were to say ldquoEveryone should do what is in the interests of Mick Jaggerrdquo I would not be making a universal judgment because I have used a proper name The same would be true if I were to say that everyone must do what is in my interests because the personal pronoun ldquomyrdquo is here used to refer to a particular individual myself

It might seem that ruling out particular terms in this way does not take us very far After all one can always describe oneself in universal terms Perhaps

Introduction 3

I canrsquot say that everyone should do what is in my interests but I could say that everyone must do whatever is in the interests of people who hellip and then give a minutely detailed description of myself including the precise location of all my freckles The effect would be the same as saying that everyone should do what is in my interests because there would be no one except me who matches that description But Hare meets this problem very effectively by saying that to prescribe an ethical judgment universally means being prepared to pre-scribe it for all possible circumstances including hypothetical ones So if I were to say that everyone should do what is in the interests of a person with a particular pattern of freckles I must be prepared to prescribe that in the hypothetical situation in which I do not have this pattern of freckles but someone else does I should do what is in the interests of that person Now of course I may say that I should do that since I am confident that I shall never be in such a situation but this simply means that I am being dishonest I am not genuinely prescribing the principle universally

The effect of saying that an ethical judgment must be universalizable for hypothetical as well as actual circumstances is that whenever I make an ethical judgment I can be challenged to put myself in the position of the parties affected and see if I would still be able to accept that judgment Suppose for example that I own a small factory and the cheapest way for me to get rid of some waste is to pour it into a nearby river I do not take water from this river but I know that some villagers living downstream do and the waste may make them ill The requirement that ethical judgments should be universalizable will make it difficult for me to justify my conduct because if I imagine myself in the hypothetical situation of being one of the villagers rather than the factory‐owner I would not accept that the profits of the factory‐owner should outweigh the risk of adverse effects on my health and that of my children In this way Harersquos approach requires us to take into account the interests and preferences of all others affected by our actions Hence it allows for an element of reasoning in ethical deliberation

Since the rightness or wrongness of our actions will on this view depend on the way in which they

affect others Harersquos universal prescriptivism leads to a form of consequentialism ndash that is the view that the rightness of an action depends on its consequences The best‐known form of consequentialism is the clas-sical utilitarianism developed in the late eighteenth century by Jeremy Bentham and popularized in the nineteenth century by John Stuart Mill They held that an action is right if it leads to a greater surplus of happiness over misery than any possible alternative and wrong if it does not By ldquogreater surplus of happinessrdquo the classical utilitarians had in mind the idea of adding up all the pleasure or happiness that resulted from the action and subtracting from that total all the pain or misery to which the action gave rise Naturally in some circumstances it might be possible only to reduce misery and then the right action should be understood as the one that will result in less misery than any possible alternative

The utilitarian view is striking in many ways It puts forward a single principle that it claims can provide the right answer to all ethical dilemmas if only we can predict what the consequences of our actions will be It takes ethics out of the mysterious realm of duties and rules and bases ethical decisions on something that almost everyone understands and values Moreover utilitarianismrsquos single principle is applied universally without fear or favor Bentham said ldquoEach to count for one and none for more than onerdquo by which he meant that the happiness of a com-mon tramp counted for as much as that of a noble and the happiness of an African was no less important than that of a European

Many contemporary consequentialists agree with Bentham to the extent that they think the rightness or wrongness of an action must depend on its conse-quences but they have abandoned the idea that m aximizing net happiness is the ultimate goal Instead they argue that we should seek to bring about w hatever will satisfy the greatest number of desires or preference This variation which is known as ldquop reference utilitarianismrdquo does not regard anything as good except in so far as it is wanted or desired More intense or strongly held preferences would get more weight than weak preferences

Consequentialism offers one important answer to the question of how we should decide what is right and what is wrong but many ethicists reject it The

4 introduction

denial of this view was dramatically presented by Dostoevsky in The Karamazov Brothers

imagine that you are charged with building the edifice of human destiny the ultimate aim of which is to bring people happiness to give them peace and contentment at last but that in order to achieve this it is essential and unavoidable to torture just one little speck of creation that same little child beating her chest with her little fists and imagine that this edifice has to be erected on her unexpiated tears Would you agree to be the architect under those conditions Tell me honestly2

The passage suggests that some things are always wrong no matter what their consequences This has for most of Western history been the prevailing approach to morality at least at the level of what has been officially taught and approved by the institutions of Church and State The ten commandments of the Hebrew scriptures served as a model for much of the Christian era and the Roman Catholic Church built up an elaborate system of morality based on rules to which no exceptions were allowed

Another example of an ethic of rules is that of Immanuel Kant Kantrsquos ethic is based on his ldquocategori-cal imperativerdquo which he states in several distinct for-mulations One is that we must always act so that we can will the maxim of our action to be a universal law This can be interpreted as a form of Harersquos idea of universalizability which we have already encountered Another is that we must always treat other people as ends never as means While these formulations of the categorical imperative might be applied in various ways in Kantrsquos hands they lead to inviolable rules for example against making promises that we do not intend to keep Kant also thought that it was always wrong to tell a lie In response to a critic who sug-gested that this rule has exceptions Kant said that it would be wrong to lie even if someone had taken refuge in your house and a person seeking to murder him came to your door and asked if you knew where he was Modern Kantians often reject this hard-line approach to rules and claim that Kantrsquos categorical imperative did not require him to hold so strictly to the rule against lying

How would a consequentialist ndash for example a classical utilitarian ndash answer Dostoevskyrsquos challenge If answering honestly ndash and if one really could be certain

that this was a sure way and the only way of bringing lasting happiness to all the people of the world ndash utilitarians would have to say yes they would accept the task of being the architect of the happiness of the world at the cost of the childrsquos unexpiated tears For they would point out that the suffering of that child wholly undeserved as it is will be repeated a million‐fold over the next century for other children just as innocent who are victims of starvation disease and brutality So if this one child must be sacrificed to stop all this suffering then terrible as it is the child must be sacrificed

Fantasy apart there can be no architect of the hap-piness of the world The world is too big and complex a place for that But we may attempt to bring about less suffering and more happiness or satisfaction of preferences for people or sentient beings in specific places and circumstances Alternatively we might fol-low a set of principles or rules ndash which could be of varying degrees of rigidity or flexibility Where would such rules come from Kant tried to deduce them from his categorical imperative which in turn he had reached by insisting that the moral law must be based on reason alone without any content from our wants or desires But the problem with trying to deduce morality from reason alone has always been that it becomes an empty formalism that cannot tell us what to do To make it practical it needs to have some addi-tional content and Kantrsquos own attempts to deduce rules of conduct from his categorical imperative are unconvincing

Others following Aristotle have tried to draw on human nature as a source of moral rules What is good they say is what is natural to human beings They then contend that it is natural and right for us to seek certain goods such as knowledge friendship health love and procreation and unnatural and wrong for us to act contrary to these goods This ldquonatural lawrdquo ethic is open to criticism on several points The word ldquonaturalrdquo can be used both descriptively and evalua-tively and the two senses are often mixed together so that value judgments may be smuggled in under the guise of a description The picture of human nature presented by proponents of natural law ethics usually selects only those characteristics of our nature that the proponent considers desirable The fact that our species especially its male members frequently go to war and

Introduction 5

are also prone to commit individual acts of violence against others is no doubt just as much part of our nature as our desire for knowledge but no natural law theorist therefore views these activities as good More generally natural law theory has its origins in an Aristotelian idea of the cosmos in which everything has a goal or ldquoendrdquo which can be deduced from its nature The ldquoendrdquo of a knife is to cut the assumption is that human beings also have an ldquoendrdquo and we will flourish when we live in accordance with the end for which we are suited But this is a pre‐Darwinian view of nature Since Darwin we know that we do not exist for any purpose but are the result of natural selection operating on random mutations over millions of years Hence there is no reason to believe that living accord-ing to nature will produce a harmonious society let alone the best possible state of affairs for human beings

Another way in which it has been claimed that we can come to know what moral principles or rules we should follow is through our intuition In practice this usually means that we adopt conven-tionally accepted moral principles or rules perhaps with some adjustments in order to avoid inconsist-ency or arbitrariness On this view a moral theory should like a scientific theory try to match the data and the data that a moral theory must match is p rovided by our moral intuitions As in science if a plausible theory matches most but not all of the data then the anomalous data might be rejected on the grounds that it is more likely that there was an error in the procedures for gathering that particular set of data than that the theory as a whole is mis-taken But ultimately the test of a theory is its ability to explain the data The problem with applying this model of scientific justification to ethics is that the ldquodatardquo of our moral intuitions is unreliable not just at one or two specific points but as a whole Here the facts that cultural relativists draw upon are rele-vant (even if they do not establish that cultural rela-tivism is the correct response to it) Since we know that our intuitions are strongly influenced by such things as culture and religion they are ill‐suited to serve as the fixed points against which an ethical theory must be tested Even where there is cross‐cultural agreement there may be some aspects of our intuitions on which all cultures unjustifiably favor our own interests over those of others For

example simply because we are all human beings we may have a systematic bias that leads us to give an unjustifiably low moral status to nonhuman a nimals Or because in virtually all known human societies men have taken a greater leadership role than women the moral intuitions of all societies may not adequately reflect the interests of females

Some philosophers think that it is a mistake to base ethics on principles or rules Instead they focus on what it is to be a good person ndash or in the case of the problems with which this book is concerned perhaps on what it is to be a good nurse or doctor or researcher They seek to describe the virtues that a good person or a good member of the relevant profession should possess Moral education then consists of teaching these virtues and discussing how a virtuous person would act in specific situations The question is how-ever whether we can have a notion of what a virtuous person would do in a specific situation without making a prior decision about what it is right to do After all in any particular moral dilemma different virtues may be applicable and even a particular virtue will not always give unequivocal guidance For instance if a terminally ill patient repeatedly asks a nurse or doctor for assistance in dying what response best exemplifies the virtues of a healthcare professional There seems no answer to this question short of an inquiry into whether it is right or wrong to help a patient in such circumstances to die But in that case we seem bound in the end to come back to discuss-ing such issues as whether it is right to follow moral rules or principles or to do what will have the best consequences

In the late twentieth century some feminists offered new criticisms of conventional thought about ethics They argued that the approaches to ethics taken by the influential philosophers of the past ndash all of whom have been male ndash give too much emphasis to abstract principles and the role of reason and give too little attention to personal relationships and the part played by emotion One outcome of these criticisms has been the development of an ldquoethic of carerdquo which is not so much a single ethical theory as a cluster of ways of looking at ethics which put an attitude of c aring for others at the center and seek to avoid r eliance on abstract ethical principles The ethic of care has seemed especially applicable to the work of those

6 introduction

involved in direct patient care and has recently been taken up by a number of nursing theorists as offering a more suitable alternative to other ideas of ethics Not all feminists however support this development Some worry that the adoption of a ldquocarerdquo approach by nurses may reflect and even reinforce stereotypes of women as more emotional and less rational than men They also fear that it could lead to women continuing to carry a disproportionate burden of caring for others to the exclusion of adequately caring for themselves

In this discussion of ethics we have not mentioned anything about religion This may seem odd in view of the close connection that has often been made between religion and ethics but it reflects our belief that despite this historical connection ethics and reli-gion are fundamentally independent Logically ethics is prior to religion If religious believers wish to say that a deity is good or praise her or his creation or deeds they must have a notion of goodness that is independent of their conception of the deity and what she or he does Otherwise they will be saying that the deity is good and when asked what they mean by ldquogoodrdquo they will have to refer back to the deity saying perhaps that ldquogoodrdquo means ldquoin accord-ance with the wishes of the deityrdquo In that case sen-tences such as ldquoGod is goodrdquo would be a meaningless tautology ldquoGod is goodrdquo could mean no more than ldquoGod is in accordance with Godrsquos wishesrdquo As we have already seen there are ideas of what it is for something to be ldquogoodrdquo that are not rooted in any religious belief While religions typically encourage or instruct their followers to obey a particular ethical code it is obvious that others who do not follow any religion can also think and act ethically

To say that ethics is independent of religion is not to deny that theologians or other religious believers may have a role to play in bioethics Religious traditions often have long histories of dealing with ethical dilem-mas and the accumulation of wisdom and experience that they represent can give us valuable insights into particular problems But these insights should be subject to criticism in the way that any other proposals would be If in the end we accept them it is because we have judged them sound not because they are the utterances of a pope a rabbi a mullah or a holy person

Ethics is also independent of the law in the sense that the rightness or wrongness of an act cannot be

settled by its legality or illegality Whether an act is legal or illegal may often be relevant to whether it is right or wrong because it is arguably wrong to break the law other things being equal Many people have thought that this is especially so in a democracy in which everyone has a say in making the law Another reason why the fact that an act is illegal may be a rea-son against doing it is that the legality of an act may affect the consequences that are likely to flow from it If active voluntary euthanasia is illegal then doctors who practice it risk going to jail which will cause them and their families to suffer and also mean that they will no longer be able to help other patients This can be a powerful reason for not practicing voluntary euthanasia when it is against the law but if there is only a very small chance of the offense becoming known or being proved then the weight of this con-sequentialist reason against breaking the law is reduced accordingly Whether we have an ethical obligation to obey the law and if so how much weight should be given to it is itself an issue for ethical argument

Though ethics is independent of the law in the sense just specified laws are subject to evaluation from an ethical perspective Many debates in bioethics focus on questions about what practices should be allowed ndash for example should we allow research on stem cells taken from human embryos sex selection or cloning ndash and committees set up to advise on the ethical social and legal aspects of these questions often recommend legislation to prohibit the activity in question or to allow it to be practiced under some form of regulation Discussing a question at the level of law and public policy however raises somewhat different considerations than a discussion of personal ethics because the consequences of adopting a public policy generally have much wider ramifications than the consequences of a personal choice That is why some healthcare professionals feel justified in assisting a terminally ill patient to die while at the same time opposing the legalization of physician‐assisted suicide Paradoxical as this position may appear ndash and it is certainly open to criticism ndash it is not straightforwardly inconsistent

Naturally many of the essays we have selected reflect the times in which they were written Since bioethics often comments on developments in fast‐moving

Introduction 7

areas of medicine and the biological sciences the factual content of articles in bioethics can become obsolete quite rapidly In preparing this revised edition we have taken the opportunity to cover some new issues and to include some more recent writings We have for example included new mate-rial on genetic enhancement as well as on the use of embryonic human stem cells This edition of the anthology also includes new sections on ethical issues in public health and in the neurosciences Nevertheless an article that has dated in regard to its facts often makes ethical points that are still valid

or worth considering so we have not excluded older articles for this reason

Other articles are dated in a different way During the past few decades we have become more sensitive about the ways in which our language may exclude women or reflect our prejudices regarding race or sexuality We see no merit in trying to disguise past practices on such matters so we have not excluded otherwise valuable works in bioethics on these grounds If they are jar-ring to the modern reader that may be a salutary reminder of the extent to which we all are subject to the conventions and prejudices of our times

Notes

1 See Van Rensselaer Potter Bioethics Bridge to the Future (Englewood Cliffs NJ Prentice‐Hall 1971)

2 The Karamazov Brothers trans Ignat Avsey (Oxford Oxford University Press 1994) vol I part 2 bk 5 ch 4 First published in 1879

Abortion

Part I

Acknowledgments xiii

14 John A Robertson Jeffrey P Kahn and John E Wagner ldquoConception to Obtain Hematopoietic Stem Cellsrdquo pp 34ndash40 from Hastings Center Report 32 3 (MayJune 2002) Reproduced with permission from John Wiley amp Sons

15 David King ldquoWhy We Should Not Permit Embryos to Be Selected as Tissue Donorsrdquo pp 13ndash16 from The Bulletin of Medical Ethics 190 (August 2003) Copyright copy RSM Press 2003 Reproduced by permission of SAGE Publications Ltd London Los Angeles New Delhi Singapore and Washington DC

16 Michael Tooley ldquoThe Moral Status of the Cloning of Humansrdquo pp 67ndash101 from James M Humber and Robert I Almeder (eds) Human Cloning Totowa NJ Humana Press 1998 With kind permission from Springer Science+Business Media

17 Jonathan Glover ldquoQuestions about Some Uses of Genetic Engineeringrdquo pp 25ndash33 33ndash6 42ndash3 and 45ndash53 from What Sort of People Should There Be Harmondsworth Penguin Books 1984 Reproshyduced by permission of Penguin Books Ltd

18 David B Resnik ldquoThe Moral Significance of the TherapyndashEnhancement Distinction in Human Geneticsrdquo pp 365ndash77 from Cambridge Quarterly of Healthcare Ethics 9 3 (Summer 2000) copy Cambridge University Press Reproduced with permission

19 Ainsley Newson and Robert Williamson ldquoShould We Undertake Genetic Research on Intelligencerdquo pp 327ndash42 from Bioethics 13 34 (1999) Reproduced with permission from John Wiley amp Sons

20 Nick Bostrom ldquoIn Defense of Posthuman Dignityrdquo pp 202ndash14 from Bioethics 19 3 (2005) Reproduced with permission from John Wiley amp Sons

21 Jonathan Glover ldquoThe Sanctity of Liferdquo pp 39ndash59 from Causing Death and Lives London Pelican 1977 Reproduced by permission of Penguin Books Ltd

22 Sacred Congregation for the Doctrine of the Faith ldquoDeclaration on Euthanasiardquo Vatican City 1980

23 Germain Grisez and Joseph M Boyle Jr ldquoThe Morality of Killing A Traditional Viewrdquo

pp 381ndash419 from Life and Death with Liberty and Justice A Contribution to the Euthanasia Debate Notre Dame IN University of Notre Dame Press 1971

24 James Rachels ldquoActive and Passive Euthanasiardquo pp 78ndash80 from New England Journal of Medicine 292 (1975) Copyright copy 1975 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

25 Winston Nesbitt ldquoIs Killing No Worse Than Letting Dierdquo pp 101ndash5 from Journal of Applied Philosophy 12 1 (1995) Reproduced with permission from John Wiley amp Sons

26 Helga Kuhse ldquoWhy Killing Is Not Always Worse ndash and Sometimes Better ndash Than Letting Dierdquo pp 371ndash4 from Cambridge Quarterly of Healthcare 7 4 (1998) copy Cambridge University Press Reproduced with permission

27 Franklin G Miller Robert D Truog and Dan W Brock ldquoMoral Fictions and Medical Ethicsrdquo pp 453ndash60 from Bioethics 24 9 (2010) Reproduced with permission from John Wiley amp Sons

28 Neil Campbell ldquoWhen Care Cannot Cure Medical Problems in Seriously Ill Babiesrdquo pp 327ndash44 from F K Beller and R F Weir (eds) The Beginning of Human Life Dordrecht Kluwer Academic Publishers 1994 With kind pershymission from Springer Science+Business Media

29 R M Hare ldquoThe Abnormal Child Moral Dilemmas of Doctors and Parentsrdquo Reprinted in Essays on Bioethics Oxford Clarendon Press 1993 pp185ndash91 Courtesy of the Estate of R M Hare

30 Alison Davis ldquoRight to Life of Handicappedrdquo p 181 from Journal of Medical Ethics 9 (1983) Reproduced with permission from BMJ Publishing Group

31 Christine Overall ldquoConjoined Twins Embodied Personhood and Surgical Separationrdquo pp 69ndash84 from L Tessman (ed) Feminist Ethics and Social and Political Philosophy Theorizing the Non‐Ideal Springer 2009 With kind permission from Springer Science+Business Media

32 Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death ldquolsquoA Definition of Irreversible Comarsquo Report to Examine the Definition of Brain

xiv acknowledgments

Deathrdquo pp 85ndash8 from Journal of the American Medical Association 205 6 (August 1968) Copyright copy 1968 American Medical Association All rights reserved

33 Ari Joffe ldquoAre Recent Defences of the Brain Death Concept Adequaterdquo pp 47ndash53 from Bioethics 24 2 (February 2010) Reproduced with permission from John Wiley amp Sons

34 Peter Singer ldquoIs the Sanctity of Life Ethic Terminally Illrdquo pp 307ndash43 from Bioethics 9 34 (1995) Reproduced with permission from John Wiley amp Sons

35 Ronald Dworkin ldquoLife Past Reasonrdquo pp 218ndash29 from Lifersquos Dominion An Argument about Abortion Euthanasia and Individual Freedom New York Knopf 1993 Copyright copy 1993 by Ronald Dworkin Used by permission of Alfred A Knopf an imprint of the Knopf Doubleday Publishing Group a division of Random House LLC All rights reserved

36 Rebecca Dresser ldquoDworkin on Dementia Elegant Theory Questionable Policyrdquo pp 32ndash8 from Hastings Center Report 25 6 (NovemberDecember 1995) Reproduced with permission from John Wiley amp Sons

37 Chris Hill ldquoThe Noterdquo pp 9ndash17 from Helga Kuhse (ed) Willing to Listen Wanting to Die Ringwood Australia Penguin Books 1994

38 Daniel Callahan ldquoWhen Self‐Determination Runs Amokrdquo pp 52ndash5 from Hastings Center Report 22 2 (MarchApril 1992) Reproduced with permission from John Wiley amp Sons

39 John Lachs ldquoWhen Abstract Moralizing Runs Amokrdquo pp 10ndash13 from The Journal of Clinical Ethics 5 1 (Spring 1994) Copyright JCE

40 Bregje D Onwuteaka‐Philipsen et al ldquoTrends in End‐Of‐Life Practices Before and After the Enactment of the Euthanasia Law in the Netherlands from 1990 to 2010 A Repeated Cross‐Sectional Surveyrdquo pp 908ndash15 from The Lancet 380 9845 (2012) Reprinted from The Lancet with permission from Elsevier

41 Bernard Lo ldquoEuthanasia in the Netherlands What Lessons for Elsewhererdquo pp 869ndash70 from The Lancet 380 (September 8 2012) Copyright 2012 Reprinted from The Lancet with permisshysion from Elsevier

42 Paul T Menzel ldquoRescuing Lives Canrsquot We Countrdquo pp 22ndash3 from Hastings Center Report 24 1 (1994) Reproduced with permission from John Wiley amp Sons

43 Alvin H Moss and Mark Siegler ldquoShould Alcoholics Compete Equally for Liver Transshyplantationrdquo pp 1295ndash8 from Journal of the American Medical Association 265 10 (1991) Copyright copy 1991 American Medical Association All rights reserved

44 John Harris ldquoThe Value of Liferdquo pp 87ndash102 from The Value of Life London Routledge 1985 Copyright 1985 Routledge Reproduced by permission of Taylor amp Francis Books UK

45 Nick Beckstead and Toby Ord ldquoBubbles under the Wallpaper Healthcare Rationing and Disshycriminationrdquo a paper presented to the confershyence ldquoValuing Livesrdquo New York University March 5 2011 copy Nick Beckstead and Toby Ord reprinted by permission of the authors This paper is published here for the first time but draws on Nick Beckstead and Toby Ord ldquoRationing and Rationality The Cost of Avoiding Discriminationrdquo in N Eyal et al (eds) Inequalities in Health Concepts Measures and Ethics Oxford Oxford University Press 2013 pp 232ndash9 By permission of Oxford University Press

46 Eike‐Henner W Kluge ldquoOrgan Donation and Retrieval Whose Body Is It Anywayrdquo copy 1999 by Eike‐Henner W Kluge

47 Janet Radcliffe‐Richards et al ldquoThe Case for Allowing Kidney Salesrdquo pp 1950ndash2 from The Lancet 351 9120 (June 27 1998) Reprinted with permission from Elsevier

48 Debra Satz ldquoEthical Issues in the Supply and Demand of Human Kidneysrdquo pp 189ndash206 from Why Some Things Should Not Be for Sale The Moral Limits of Markets New York Oxford University Press 2010 ch 9 based on an article from Proceedings of the Aristotelian Society Reprinted by courtesy of the Editor of Proceedings of the Aristotelian Society copy 2010

49 John Harris ldquoThe Survival Lotteryrdquo pp 81ndash7 from Philosophy 50 (1975) copy Royal Institute of Philosophy published by Cambridge University Press Reproduced with permission

Acknowledgments xv

50 Henry K Beecher ldquoEthics and Clinical Researchrdquo pp 1354ndash60 from New England Journal of Medicine 274 24 (June 1966) Copyright copy 1996 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

51 Benjamin Freedman ldquoEquipoise and the Ethics of Clinical Researchrdquo pp 141ndash5 from New England Journal of Medicine 317 3 (July 1987) Copyright copy 1987 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

52 Samuel Hellman ldquoThe Patient and the Public Goodrdquo pp 400ndash2 from Nature Medicine 1 5 (1995) Reprinted by permission from Macmillan Publishers Ltd

53 John Harris ldquoScientific Research Is a Moral Dutyrdquo pp 242ndash8 from Journal of Medical Ethics 31 4 (2005) Reproduced with permission from BMJ Publishing Group

54 Sandra Shapshay and Kenneth D Pimple ldquoParticipation in Research Is an Imperfect Moral Duty A Response to John Harrisrdquo pp 414ndash17 from Journal of Medical Ethics 33 (2007) Reproduced with permission from BMJ Publishing Group

55 Peter Lurie and Sidney M Wolfe ldquoUnethical Trials of Interventions to Reduce Perinatal Transmission of the Human Immunodeficiency Virus in Developing Countriesrdquo pp 853ndash6 from New England Journal of Medicine 337 12 (September 1997) Copyright copy 1997 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

56 Danstan Bageda and Philippa Musoke‐Mudido ldquoWersquore Trying to Help Our Sickest People Not Exploit Themrdquo from The Washington Post September 28 1997 copy 1997 Washington Post Company All rights reserved Used by permisshysion and protected by the Copyright Laws of the United States The printing copying redistribushytion or retransmission of this Content without express written permission is prohibited

57 Leah Belsky and Henry S Richardson ldquoMedical Researchersrsquo Ancillary Clinical Care Respon sibilitiesrdquo pp 1494ndash6 from British

Medical Journal 328 (June 19 2004) Reproduced with permission from BMJ Publishing Group

58 George W Bush ldquoPresident Discusses Stem Cell Researchrdquo Office of the Press Secretary White House August 9 2001

59 Jeff McMahan ldquoKilling Embryos for Stem Cell Researchrdquo pp 170ndash89 from Metaphilosophy 38 23 (2007) Reproduced with permission from John Wiley amp Sons

60 Immanuel Kant ldquoDuties towards Animalsrdquo pp 239ndash41 from Lectures on Ethics trans Louis Infield London Methuen 1930 Copyright 1930 Methuen reproduced by permission of Taylor amp Francis Books UK

61 Jeremy Bentham ldquoA Utilitarian Viewrdquo section XVIII IV from An Introduction to the Principles of Morals and Legislation First published c1820

62 Peter Singer ldquoAll Animals are Equalrdquo pp 103ndash16 from Philosophic Exchange 1 5 (1974) Center for Philosophic Exchange State University of New York Brockford NY 1974

63 R G Frey and Sir William Paton ldquoVivisection Morals and Medicine An Exchangerdquo pp 94ndash7 and 102ndash4 from Journal of Medical Ethics 9 (1983) Reproduced with permission from BMJ Publishing Group

64 Michael J Selgelid ldquoEthics and Infectious Diseaserdquo pp 272ndash89 from Bioethics 19 3 (2005) Reproduced with permission from John Wiley amp Sons

65 Udo Schuumlklenk and Anita Kleinsmidt ldquoRethinking Mandatory HIV Testing during Pregnancy in Areas with High HIV Prevalence Rates Ethical and Policy Issuesrdquo pp 1179ndash83 from American Journal of Public Health 97 7 (2007) Reproduced with permission from American Public Health Association

66 Russell Armstrong ldquoMandatory HIV Testing in Pregnancy Is There Ever a Timerdquo pp 1ndash10 from Developing World Bioethics 8 1 (2008) Reproduced with permission from John Wiley amp Sons

67 Jerome Amir Singh Ross Upshur and Nesri Padayatchi ldquoXDR‐TB in South Africa No Time for Denial or Complacencyrdquo PLoS Med 4 1 (2007) e50 doi101371journalpmed0040050 Copyright copy 2007 Singh et al

xvi acknowledgments

68 Mark Siegler ldquoConfidentiality in Medicine A Decrepit Conceptrdquo pp 1518ndash21 from New England Journal of Medicine 307 24 (December 1982) Copyright copy 1982 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

69 Christian Saumlfken and Andreas Frewer ldquoThe Duty to Warn and Clinical Ethics Legal and Ethical Aspects of Confidentiality and HIVAIDSrdquo pp 313ndash326 from HEC Forum 19 4 (2007) With kind permission from Springer Science+Business Media

70 Immanuel Kant ldquoOn a Supposed Right to Lie from Altruistic Motivesrdquo pp 361ndash3 from Critique of Practical Reason and Other Works on the Theory of Ethics 6th edition trans T K Abbott London 1909 This essay was first published in a Berlin periodical in 1797

71 Joseph Collins ldquoShould Doctors Tell the Truthrdquo pp 320ndash6 from Harperrsquos Monthly Magazine 155 (August 1927) Copyright copy 1927 Harperrsquos Magazine All rights reserved Reproduced from the August issue by special permission

72 Roger Higgs ldquoOn Telling Patients the Truthrdquo pp 186ndash202 and 232ndash3 from Michael Lockwood (ed) Moral Dilemmas in Modern Medicine Oxford Oxford University Press 1985 By permission of Oxford University Press

73 John Stuart Mill ldquoOn Libertyrdquo first published in 1859

74 Justice Benjamin N Cardozo Judgment from Schloendorff v New York Hospital (1914) p 526 from Jay Katz (ed) Experimentation with Human Beings The Authority of the Investigator Subject Professions and State in the Human Experimentation Process New York Russell Sage Foundation 1972 Reproduced with permission of Russell Sage Foundation

75 Tom L Beauchamp ldquoInformed Consent Its History Meaning and Present Challengesrdquo pp 515ndash23 from Cambridge Quarterly of Health Care Ethics 20 4 (2011) copy Royal Institute of Philosophy published by Cambridge University Press Reproduced with permission from Cambridge University Press and T Beauchamp

76 Ruth Macklin ldquoThe DoctorndashPatient Relationshyship in Different Culturesrdquo pp 86ndash107 from

Against Relativism Cultural Diversity and the Search of Ethical Universals in Medicine copy 1999 by Oxford University Press Inc By permission of Oxford University Press USA

77 Carl Elliott ldquoAmputees by Choicerdquo pp 208ndash10 210ndash15 219ndash23 227ndash31 234ndash6 323ndash6 from Better Than Well American Medicine Meets the American Dream New York and London WW Norton 2003 Copyright copy 2003 by Carl Elliott Used by permission of W W Norton amp Company Inc

78 Julian Savulescu ldquoRational Desires and the Limishytation of Life‐Sustaining Treatmentrdquo pp 191ndash 222 from Bioethics 8 3 (1994) Reproduced with permission from John Wiley amp Sons

79 Shlomo Cohen ldquoThe Nocebo Effect of Informed Consentrdquo pp 147ndash54 from Bioethics 28 3 (2014) Reproduced with permission from John Wiley amp Sons

80 Sarah E Dock ldquoThe Relation of the Nurse to the Doctor and the Doctor to the Nurserdquo p 394 (extract) from The American Journal of Nursing 17 5 (1917)

81 Lisa H Newton ldquoIn Defense of the Traditional Nurserdquo pp 348ndash54 from Nursing Outlook 29 6 (1981) Copyright Elsevier 1981

82 Sarah Breier ldquoPatient Autonomy and Medical Paternity Can Nurses Help Doctors to Listen to Patientsrdquo pp 510ndash21 from Nursing Ethics 8 6 (2001) Reproduced with permission from Sage and S Breier

83 Carol Pavlish Anita Ho and Ann‐Marie Rounkle ldquoHealth and Human Rights Advocacy Perspectives from a Rwandan Refugee Camprdquo pp 538ndash49 from Nursing Ethics 19 4 (2012) Copyright copy 2012 by SAGE Publications Reprinted by Permission of SAGE

84 Jonathan D Moreno ldquoNeuroethics An Agenda for Neuroscience and Societyrdquo pp 149ndash53 from Nature Reviews 4 (February 2003)Reprinted by permission from Macmillan Publishers Ltd

85 Sally Adee ldquoHow Electrical Brain Stimulation Can Change the Way We Thinkrdquo The Week March 30 2012

86 Neil Levy ldquoNeuroethics Ethics and the Sciences of the Mindrdquo pp 69ndash74 (extract) from Philosophy

Acknowledgments xvii

Compass 4 10 (2009) pp 69ndash81 Reproduced with permission from John Wiley amp Sons

87 Adam Kolber ldquoFreedom of Memory Todayrdquo pp 145ndash8 from Neuroethics 1 (2008) With kind permission from Springer Science+Business Media

88 Henry Greely and Colleagues ldquoTowards Responsible Use of Cognitive‐Enhancing Drugs

by the Healthyrdquo pp 702ndash5 from Nature 456 (December 11 2008) Reprinted by permission from Macmillan Publishers Ltd

89 Julian Savulescu and Anders Sandberg ldquoEngineering LoverdquoldquoLove Machine Engineering Lifelong Romancerdquo pp 28ndash9 from New Scientist 2864 copy 2012 Reed Business Information ndash UK All rights reserved Distributed by Tribune Content Agency

Bioethics An Anthology Third Edition Edited by Helga Kuhse Udo Schuumlklenk and Peter Singer copy 2016 John Wiley amp Sons Inc Published 2016 by John Wiley amp Sons Inc

Introduction

The term ldquobioethicsrdquo was coined by Van Rensselaer Potter who used it to describe his proposal that we need an ethic that can incorporate our obligations not just to other humans but to the biosphere as a whole1 Although the term is still occasionally used in this sense of an ecological ethic it is now much more commonly used in the narrower sense of the study of ethical issues arising from the biological and medical sciences So understood bioethics has become a specialized although interdisciplinary area of study The essays included in this book give an indication of the range of issues which fall within its scope ndash but it is only an indication There are many other issues that we simply have not had the space to cover

Bioethics can be seen as a branch of ethics or more specifically of applied ethics For this reason some understanding of the nature of ethics is an essential preliminary to any serious study of bioethics The remainder of this introduction will seek to provide that understanding

One question about the nature of ethics is especially relevant to bioethics to what extent is reasoning or argument possible in ethics Many people assume without much thought that ethics is subjective The subjectivist holds that what ethical view we take is a matter of opinion or taste that is not amenable to argument But if ethics were a matter of taste why would we even attempt to argue about it If Helen says ldquoI like my coffee sweetenedrdquo whereas Paul says

ldquoI like my coffee unsweetenedrdquo there is not much point in Helen and Paul arguing about it The two statements do not contradict each other They can both be true But if Helen says ldquoDoctors should never assist their patients to dierdquo whereas Paul says ldquoSometimes doctors should assist their patients to dierdquo then Helen and Paul are disagreeing and there does seem to be a point in their trying to argue about the issue of physician‐assisted suicide

It seems clear that there is some scope for argument in ethics If I say ldquoIt is always wrong to kill a human beingrdquo and ldquoAbortion is not always wrongrdquo then I am committed to denying that abortion kills a human being Otherwise I have contradicted myself and in doing so I have not stated a coherent position at all So consistency at least is a requirement of any defensible ethical position and thus sets a limit to the subjectivity of ethical judgments The requirement of factual accuracy sets another limit In discussing issues in bioethics the facts are often complex But we cannot reach the right ethical decisions unless we are well‐informed about the relevant facts In this respect ethical decisions are unlike decisions of taste We can enjoy a taste without knowing what we are eating but if we assume that it is wrong to resuscitate a terminally ill patient against her wishes then we can-not know whether an instance of resuscitation was morally right or wrong without knowing something about the patientrsquos prognosis and whether the patient

2 introduction

has expressed any wishes about being resuscitated In that sense there is no equivalent in ethics to the immediacy of taste

Ethical relativism sometimes also known as cul-tural relativism is one step away from ethical sub-jectivism but it also severely limits the scope of ethical argument The ethical relativist holds that it is not individual attitudes that determine what is right or wrong but the attitudes of the culture in which one lives Herodotus tells how Darius King of Persia summoned the Greeks from the western shores of his kingdom before him and asked them how much he would have to pay them to eat their fathersrsquo dead bodies They were horrified by the idea and said they would not do it for any amount of money for it was their custom to cremate their dead Then Darius called upon Indians from the eastern frontiers of his kingdom and asked them what would make them willing to burn their fathersrsquo bodies They cried out and asked the King to refrain from mentioning so shocking an act Herodotus comments that each nation thinks its own customs best From here it is only a short step to the view that there can be no objective right or wrong beyond the bounds of onersquos own culture This view found increased support in the nine-teenth century as Western anthropologists came to know many different cultures and were impressed by ethical views very different from those that were standardly taken for granted in European society As a defense against the automatic assumption that Western morality is superior and should be imposed on ldquosavagesrdquo many anthropologists argued that since morality is relative to culture no culture can have any basis for regarding its morality as superior to any other culture

Although the motives with which anthropolo-gists put this view forward were admirable they may not have appreciated the implications of the position they were taking The ethical relativist maintains that a statement like ldquoIt is good to enslave people from another tribe if they are captured in warrdquo means simply ldquoIn my society the custom is to enslave people from another tribe if they are cap-tured in warrdquo Hence if one member of the society were to question whether it really was good to enslave people in these circumstances she could be

answered simply by demonstrating that this was indeed the custom ndash for example by showing that for many generations it had been done after every war in which prisoners were captured Thus there is no way for moral reformers to say that an accepted custom is wrong ndash ldquowrongrdquo just means ldquoin accord-ance with an accepted customrdquo

On the other hand when people from two different cultures disagree about an ethical issue then according to the ethical relativist there can be no resolution of the disagreement Indeed strictly there is no disagree-ment If the apparent dispute were over the issue just mentioned then one person would be saying ldquoIn my country it is the custom to enslave people from another tribe if they are captured in warrdquo and the other person would be saying ldquoIn my country it is not the custom to allow one human being to enslave anotherrdquo This is no more a disagreement than such statements as ldquoIn my country people greet each other by rubbing nosesrdquo and ldquoIn my country people greet each other by shaking handsrdquo If ethical relativism is true then it is impossible to say that one culture is right and the other is wrong Bearing in mind that some cultures have practiced slavery or the burning of widows on the funeral pyre of their husbands this is hard to accept

A more promising alternative to both ethical subjectivism and cultural relativism is universal pre-scriptivism an approach to ethics developed by the Oxford philosopher R M Hare Hare argues that the distinctive property of ethical judgments is that they are universalizable In saying this he means that if I make an ethical judgment I must be prepared to state it in universal terms and apply it to all relevantly similar situations By ldquouniversal termsrdquo Hare means those terms that do not refer to a particular individual Thus a proper name cannot be a universal term If for example I were to say ldquoEveryone should do what is in the interests of Mick Jaggerrdquo I would not be making a universal judgment because I have used a proper name The same would be true if I were to say that everyone must do what is in my interests because the personal pronoun ldquomyrdquo is here used to refer to a particular individual myself

It might seem that ruling out particular terms in this way does not take us very far After all one can always describe oneself in universal terms Perhaps

Introduction 3

I canrsquot say that everyone should do what is in my interests but I could say that everyone must do whatever is in the interests of people who hellip and then give a minutely detailed description of myself including the precise location of all my freckles The effect would be the same as saying that everyone should do what is in my interests because there would be no one except me who matches that description But Hare meets this problem very effectively by saying that to prescribe an ethical judgment universally means being prepared to pre-scribe it for all possible circumstances including hypothetical ones So if I were to say that everyone should do what is in the interests of a person with a particular pattern of freckles I must be prepared to prescribe that in the hypothetical situation in which I do not have this pattern of freckles but someone else does I should do what is in the interests of that person Now of course I may say that I should do that since I am confident that I shall never be in such a situation but this simply means that I am being dishonest I am not genuinely prescribing the principle universally

The effect of saying that an ethical judgment must be universalizable for hypothetical as well as actual circumstances is that whenever I make an ethical judgment I can be challenged to put myself in the position of the parties affected and see if I would still be able to accept that judgment Suppose for example that I own a small factory and the cheapest way for me to get rid of some waste is to pour it into a nearby river I do not take water from this river but I know that some villagers living downstream do and the waste may make them ill The requirement that ethical judgments should be universalizable will make it difficult for me to justify my conduct because if I imagine myself in the hypothetical situation of being one of the villagers rather than the factory‐owner I would not accept that the profits of the factory‐owner should outweigh the risk of adverse effects on my health and that of my children In this way Harersquos approach requires us to take into account the interests and preferences of all others affected by our actions Hence it allows for an element of reasoning in ethical deliberation

Since the rightness or wrongness of our actions will on this view depend on the way in which they

affect others Harersquos universal prescriptivism leads to a form of consequentialism ndash that is the view that the rightness of an action depends on its consequences The best‐known form of consequentialism is the clas-sical utilitarianism developed in the late eighteenth century by Jeremy Bentham and popularized in the nineteenth century by John Stuart Mill They held that an action is right if it leads to a greater surplus of happiness over misery than any possible alternative and wrong if it does not By ldquogreater surplus of happinessrdquo the classical utilitarians had in mind the idea of adding up all the pleasure or happiness that resulted from the action and subtracting from that total all the pain or misery to which the action gave rise Naturally in some circumstances it might be possible only to reduce misery and then the right action should be understood as the one that will result in less misery than any possible alternative

The utilitarian view is striking in many ways It puts forward a single principle that it claims can provide the right answer to all ethical dilemmas if only we can predict what the consequences of our actions will be It takes ethics out of the mysterious realm of duties and rules and bases ethical decisions on something that almost everyone understands and values Moreover utilitarianismrsquos single principle is applied universally without fear or favor Bentham said ldquoEach to count for one and none for more than onerdquo by which he meant that the happiness of a com-mon tramp counted for as much as that of a noble and the happiness of an African was no less important than that of a European

Many contemporary consequentialists agree with Bentham to the extent that they think the rightness or wrongness of an action must depend on its conse-quences but they have abandoned the idea that m aximizing net happiness is the ultimate goal Instead they argue that we should seek to bring about w hatever will satisfy the greatest number of desires or preference This variation which is known as ldquop reference utilitarianismrdquo does not regard anything as good except in so far as it is wanted or desired More intense or strongly held preferences would get more weight than weak preferences

Consequentialism offers one important answer to the question of how we should decide what is right and what is wrong but many ethicists reject it The

4 introduction

denial of this view was dramatically presented by Dostoevsky in The Karamazov Brothers

imagine that you are charged with building the edifice of human destiny the ultimate aim of which is to bring people happiness to give them peace and contentment at last but that in order to achieve this it is essential and unavoidable to torture just one little speck of creation that same little child beating her chest with her little fists and imagine that this edifice has to be erected on her unexpiated tears Would you agree to be the architect under those conditions Tell me honestly2

The passage suggests that some things are always wrong no matter what their consequences This has for most of Western history been the prevailing approach to morality at least at the level of what has been officially taught and approved by the institutions of Church and State The ten commandments of the Hebrew scriptures served as a model for much of the Christian era and the Roman Catholic Church built up an elaborate system of morality based on rules to which no exceptions were allowed

Another example of an ethic of rules is that of Immanuel Kant Kantrsquos ethic is based on his ldquocategori-cal imperativerdquo which he states in several distinct for-mulations One is that we must always act so that we can will the maxim of our action to be a universal law This can be interpreted as a form of Harersquos idea of universalizability which we have already encountered Another is that we must always treat other people as ends never as means While these formulations of the categorical imperative might be applied in various ways in Kantrsquos hands they lead to inviolable rules for example against making promises that we do not intend to keep Kant also thought that it was always wrong to tell a lie In response to a critic who sug-gested that this rule has exceptions Kant said that it would be wrong to lie even if someone had taken refuge in your house and a person seeking to murder him came to your door and asked if you knew where he was Modern Kantians often reject this hard-line approach to rules and claim that Kantrsquos categorical imperative did not require him to hold so strictly to the rule against lying

How would a consequentialist ndash for example a classical utilitarian ndash answer Dostoevskyrsquos challenge If answering honestly ndash and if one really could be certain

that this was a sure way and the only way of bringing lasting happiness to all the people of the world ndash utilitarians would have to say yes they would accept the task of being the architect of the happiness of the world at the cost of the childrsquos unexpiated tears For they would point out that the suffering of that child wholly undeserved as it is will be repeated a million‐fold over the next century for other children just as innocent who are victims of starvation disease and brutality So if this one child must be sacrificed to stop all this suffering then terrible as it is the child must be sacrificed

Fantasy apart there can be no architect of the hap-piness of the world The world is too big and complex a place for that But we may attempt to bring about less suffering and more happiness or satisfaction of preferences for people or sentient beings in specific places and circumstances Alternatively we might fol-low a set of principles or rules ndash which could be of varying degrees of rigidity or flexibility Where would such rules come from Kant tried to deduce them from his categorical imperative which in turn he had reached by insisting that the moral law must be based on reason alone without any content from our wants or desires But the problem with trying to deduce morality from reason alone has always been that it becomes an empty formalism that cannot tell us what to do To make it practical it needs to have some addi-tional content and Kantrsquos own attempts to deduce rules of conduct from his categorical imperative are unconvincing

Others following Aristotle have tried to draw on human nature as a source of moral rules What is good they say is what is natural to human beings They then contend that it is natural and right for us to seek certain goods such as knowledge friendship health love and procreation and unnatural and wrong for us to act contrary to these goods This ldquonatural lawrdquo ethic is open to criticism on several points The word ldquonaturalrdquo can be used both descriptively and evalua-tively and the two senses are often mixed together so that value judgments may be smuggled in under the guise of a description The picture of human nature presented by proponents of natural law ethics usually selects only those characteristics of our nature that the proponent considers desirable The fact that our species especially its male members frequently go to war and

Introduction 5

are also prone to commit individual acts of violence against others is no doubt just as much part of our nature as our desire for knowledge but no natural law theorist therefore views these activities as good More generally natural law theory has its origins in an Aristotelian idea of the cosmos in which everything has a goal or ldquoendrdquo which can be deduced from its nature The ldquoendrdquo of a knife is to cut the assumption is that human beings also have an ldquoendrdquo and we will flourish when we live in accordance with the end for which we are suited But this is a pre‐Darwinian view of nature Since Darwin we know that we do not exist for any purpose but are the result of natural selection operating on random mutations over millions of years Hence there is no reason to believe that living accord-ing to nature will produce a harmonious society let alone the best possible state of affairs for human beings

Another way in which it has been claimed that we can come to know what moral principles or rules we should follow is through our intuition In practice this usually means that we adopt conven-tionally accepted moral principles or rules perhaps with some adjustments in order to avoid inconsist-ency or arbitrariness On this view a moral theory should like a scientific theory try to match the data and the data that a moral theory must match is p rovided by our moral intuitions As in science if a plausible theory matches most but not all of the data then the anomalous data might be rejected on the grounds that it is more likely that there was an error in the procedures for gathering that particular set of data than that the theory as a whole is mis-taken But ultimately the test of a theory is its ability to explain the data The problem with applying this model of scientific justification to ethics is that the ldquodatardquo of our moral intuitions is unreliable not just at one or two specific points but as a whole Here the facts that cultural relativists draw upon are rele-vant (even if they do not establish that cultural rela-tivism is the correct response to it) Since we know that our intuitions are strongly influenced by such things as culture and religion they are ill‐suited to serve as the fixed points against which an ethical theory must be tested Even where there is cross‐cultural agreement there may be some aspects of our intuitions on which all cultures unjustifiably favor our own interests over those of others For

example simply because we are all human beings we may have a systematic bias that leads us to give an unjustifiably low moral status to nonhuman a nimals Or because in virtually all known human societies men have taken a greater leadership role than women the moral intuitions of all societies may not adequately reflect the interests of females

Some philosophers think that it is a mistake to base ethics on principles or rules Instead they focus on what it is to be a good person ndash or in the case of the problems with which this book is concerned perhaps on what it is to be a good nurse or doctor or researcher They seek to describe the virtues that a good person or a good member of the relevant profession should possess Moral education then consists of teaching these virtues and discussing how a virtuous person would act in specific situations The question is how-ever whether we can have a notion of what a virtuous person would do in a specific situation without making a prior decision about what it is right to do After all in any particular moral dilemma different virtues may be applicable and even a particular virtue will not always give unequivocal guidance For instance if a terminally ill patient repeatedly asks a nurse or doctor for assistance in dying what response best exemplifies the virtues of a healthcare professional There seems no answer to this question short of an inquiry into whether it is right or wrong to help a patient in such circumstances to die But in that case we seem bound in the end to come back to discuss-ing such issues as whether it is right to follow moral rules or principles or to do what will have the best consequences

In the late twentieth century some feminists offered new criticisms of conventional thought about ethics They argued that the approaches to ethics taken by the influential philosophers of the past ndash all of whom have been male ndash give too much emphasis to abstract principles and the role of reason and give too little attention to personal relationships and the part played by emotion One outcome of these criticisms has been the development of an ldquoethic of carerdquo which is not so much a single ethical theory as a cluster of ways of looking at ethics which put an attitude of c aring for others at the center and seek to avoid r eliance on abstract ethical principles The ethic of care has seemed especially applicable to the work of those

6 introduction

involved in direct patient care and has recently been taken up by a number of nursing theorists as offering a more suitable alternative to other ideas of ethics Not all feminists however support this development Some worry that the adoption of a ldquocarerdquo approach by nurses may reflect and even reinforce stereotypes of women as more emotional and less rational than men They also fear that it could lead to women continuing to carry a disproportionate burden of caring for others to the exclusion of adequately caring for themselves

In this discussion of ethics we have not mentioned anything about religion This may seem odd in view of the close connection that has often been made between religion and ethics but it reflects our belief that despite this historical connection ethics and reli-gion are fundamentally independent Logically ethics is prior to religion If religious believers wish to say that a deity is good or praise her or his creation or deeds they must have a notion of goodness that is independent of their conception of the deity and what she or he does Otherwise they will be saying that the deity is good and when asked what they mean by ldquogoodrdquo they will have to refer back to the deity saying perhaps that ldquogoodrdquo means ldquoin accord-ance with the wishes of the deityrdquo In that case sen-tences such as ldquoGod is goodrdquo would be a meaningless tautology ldquoGod is goodrdquo could mean no more than ldquoGod is in accordance with Godrsquos wishesrdquo As we have already seen there are ideas of what it is for something to be ldquogoodrdquo that are not rooted in any religious belief While religions typically encourage or instruct their followers to obey a particular ethical code it is obvious that others who do not follow any religion can also think and act ethically

To say that ethics is independent of religion is not to deny that theologians or other religious believers may have a role to play in bioethics Religious traditions often have long histories of dealing with ethical dilem-mas and the accumulation of wisdom and experience that they represent can give us valuable insights into particular problems But these insights should be subject to criticism in the way that any other proposals would be If in the end we accept them it is because we have judged them sound not because they are the utterances of a pope a rabbi a mullah or a holy person

Ethics is also independent of the law in the sense that the rightness or wrongness of an act cannot be

settled by its legality or illegality Whether an act is legal or illegal may often be relevant to whether it is right or wrong because it is arguably wrong to break the law other things being equal Many people have thought that this is especially so in a democracy in which everyone has a say in making the law Another reason why the fact that an act is illegal may be a rea-son against doing it is that the legality of an act may affect the consequences that are likely to flow from it If active voluntary euthanasia is illegal then doctors who practice it risk going to jail which will cause them and their families to suffer and also mean that they will no longer be able to help other patients This can be a powerful reason for not practicing voluntary euthanasia when it is against the law but if there is only a very small chance of the offense becoming known or being proved then the weight of this con-sequentialist reason against breaking the law is reduced accordingly Whether we have an ethical obligation to obey the law and if so how much weight should be given to it is itself an issue for ethical argument

Though ethics is independent of the law in the sense just specified laws are subject to evaluation from an ethical perspective Many debates in bioethics focus on questions about what practices should be allowed ndash for example should we allow research on stem cells taken from human embryos sex selection or cloning ndash and committees set up to advise on the ethical social and legal aspects of these questions often recommend legislation to prohibit the activity in question or to allow it to be practiced under some form of regulation Discussing a question at the level of law and public policy however raises somewhat different considerations than a discussion of personal ethics because the consequences of adopting a public policy generally have much wider ramifications than the consequences of a personal choice That is why some healthcare professionals feel justified in assisting a terminally ill patient to die while at the same time opposing the legalization of physician‐assisted suicide Paradoxical as this position may appear ndash and it is certainly open to criticism ndash it is not straightforwardly inconsistent

Naturally many of the essays we have selected reflect the times in which they were written Since bioethics often comments on developments in fast‐moving

Introduction 7

areas of medicine and the biological sciences the factual content of articles in bioethics can become obsolete quite rapidly In preparing this revised edition we have taken the opportunity to cover some new issues and to include some more recent writings We have for example included new mate-rial on genetic enhancement as well as on the use of embryonic human stem cells This edition of the anthology also includes new sections on ethical issues in public health and in the neurosciences Nevertheless an article that has dated in regard to its facts often makes ethical points that are still valid

or worth considering so we have not excluded older articles for this reason

Other articles are dated in a different way During the past few decades we have become more sensitive about the ways in which our language may exclude women or reflect our prejudices regarding race or sexuality We see no merit in trying to disguise past practices on such matters so we have not excluded otherwise valuable works in bioethics on these grounds If they are jar-ring to the modern reader that may be a salutary reminder of the extent to which we all are subject to the conventions and prejudices of our times

Notes

1 See Van Rensselaer Potter Bioethics Bridge to the Future (Englewood Cliffs NJ Prentice‐Hall 1971)

2 The Karamazov Brothers trans Ignat Avsey (Oxford Oxford University Press 1994) vol I part 2 bk 5 ch 4 First published in 1879

Abortion

Part I

xiv acknowledgments

Deathrdquo pp 85ndash8 from Journal of the American Medical Association 205 6 (August 1968) Copyright copy 1968 American Medical Association All rights reserved

33 Ari Joffe ldquoAre Recent Defences of the Brain Death Concept Adequaterdquo pp 47ndash53 from Bioethics 24 2 (February 2010) Reproduced with permission from John Wiley amp Sons

34 Peter Singer ldquoIs the Sanctity of Life Ethic Terminally Illrdquo pp 307ndash43 from Bioethics 9 34 (1995) Reproduced with permission from John Wiley amp Sons

35 Ronald Dworkin ldquoLife Past Reasonrdquo pp 218ndash29 from Lifersquos Dominion An Argument about Abortion Euthanasia and Individual Freedom New York Knopf 1993 Copyright copy 1993 by Ronald Dworkin Used by permission of Alfred A Knopf an imprint of the Knopf Doubleday Publishing Group a division of Random House LLC All rights reserved

36 Rebecca Dresser ldquoDworkin on Dementia Elegant Theory Questionable Policyrdquo pp 32ndash8 from Hastings Center Report 25 6 (NovemberDecember 1995) Reproduced with permission from John Wiley amp Sons

37 Chris Hill ldquoThe Noterdquo pp 9ndash17 from Helga Kuhse (ed) Willing to Listen Wanting to Die Ringwood Australia Penguin Books 1994

38 Daniel Callahan ldquoWhen Self‐Determination Runs Amokrdquo pp 52ndash5 from Hastings Center Report 22 2 (MarchApril 1992) Reproduced with permission from John Wiley amp Sons

39 John Lachs ldquoWhen Abstract Moralizing Runs Amokrdquo pp 10ndash13 from The Journal of Clinical Ethics 5 1 (Spring 1994) Copyright JCE

40 Bregje D Onwuteaka‐Philipsen et al ldquoTrends in End‐Of‐Life Practices Before and After the Enactment of the Euthanasia Law in the Netherlands from 1990 to 2010 A Repeated Cross‐Sectional Surveyrdquo pp 908ndash15 from The Lancet 380 9845 (2012) Reprinted from The Lancet with permission from Elsevier

41 Bernard Lo ldquoEuthanasia in the Netherlands What Lessons for Elsewhererdquo pp 869ndash70 from The Lancet 380 (September 8 2012) Copyright 2012 Reprinted from The Lancet with permisshysion from Elsevier

42 Paul T Menzel ldquoRescuing Lives Canrsquot We Countrdquo pp 22ndash3 from Hastings Center Report 24 1 (1994) Reproduced with permission from John Wiley amp Sons

43 Alvin H Moss and Mark Siegler ldquoShould Alcoholics Compete Equally for Liver Transshyplantationrdquo pp 1295ndash8 from Journal of the American Medical Association 265 10 (1991) Copyright copy 1991 American Medical Association All rights reserved

44 John Harris ldquoThe Value of Liferdquo pp 87ndash102 from The Value of Life London Routledge 1985 Copyright 1985 Routledge Reproduced by permission of Taylor amp Francis Books UK

45 Nick Beckstead and Toby Ord ldquoBubbles under the Wallpaper Healthcare Rationing and Disshycriminationrdquo a paper presented to the confershyence ldquoValuing Livesrdquo New York University March 5 2011 copy Nick Beckstead and Toby Ord reprinted by permission of the authors This paper is published here for the first time but draws on Nick Beckstead and Toby Ord ldquoRationing and Rationality The Cost of Avoiding Discriminationrdquo in N Eyal et al (eds) Inequalities in Health Concepts Measures and Ethics Oxford Oxford University Press 2013 pp 232ndash9 By permission of Oxford University Press

46 Eike‐Henner W Kluge ldquoOrgan Donation and Retrieval Whose Body Is It Anywayrdquo copy 1999 by Eike‐Henner W Kluge

47 Janet Radcliffe‐Richards et al ldquoThe Case for Allowing Kidney Salesrdquo pp 1950ndash2 from The Lancet 351 9120 (June 27 1998) Reprinted with permission from Elsevier

48 Debra Satz ldquoEthical Issues in the Supply and Demand of Human Kidneysrdquo pp 189ndash206 from Why Some Things Should Not Be for Sale The Moral Limits of Markets New York Oxford University Press 2010 ch 9 based on an article from Proceedings of the Aristotelian Society Reprinted by courtesy of the Editor of Proceedings of the Aristotelian Society copy 2010

49 John Harris ldquoThe Survival Lotteryrdquo pp 81ndash7 from Philosophy 50 (1975) copy Royal Institute of Philosophy published by Cambridge University Press Reproduced with permission

Acknowledgments xv

50 Henry K Beecher ldquoEthics and Clinical Researchrdquo pp 1354ndash60 from New England Journal of Medicine 274 24 (June 1966) Copyright copy 1996 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

51 Benjamin Freedman ldquoEquipoise and the Ethics of Clinical Researchrdquo pp 141ndash5 from New England Journal of Medicine 317 3 (July 1987) Copyright copy 1987 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

52 Samuel Hellman ldquoThe Patient and the Public Goodrdquo pp 400ndash2 from Nature Medicine 1 5 (1995) Reprinted by permission from Macmillan Publishers Ltd

53 John Harris ldquoScientific Research Is a Moral Dutyrdquo pp 242ndash8 from Journal of Medical Ethics 31 4 (2005) Reproduced with permission from BMJ Publishing Group

54 Sandra Shapshay and Kenneth D Pimple ldquoParticipation in Research Is an Imperfect Moral Duty A Response to John Harrisrdquo pp 414ndash17 from Journal of Medical Ethics 33 (2007) Reproduced with permission from BMJ Publishing Group

55 Peter Lurie and Sidney M Wolfe ldquoUnethical Trials of Interventions to Reduce Perinatal Transmission of the Human Immunodeficiency Virus in Developing Countriesrdquo pp 853ndash6 from New England Journal of Medicine 337 12 (September 1997) Copyright copy 1997 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

56 Danstan Bageda and Philippa Musoke‐Mudido ldquoWersquore Trying to Help Our Sickest People Not Exploit Themrdquo from The Washington Post September 28 1997 copy 1997 Washington Post Company All rights reserved Used by permisshysion and protected by the Copyright Laws of the United States The printing copying redistribushytion or retransmission of this Content without express written permission is prohibited

57 Leah Belsky and Henry S Richardson ldquoMedical Researchersrsquo Ancillary Clinical Care Respon sibilitiesrdquo pp 1494ndash6 from British

Medical Journal 328 (June 19 2004) Reproduced with permission from BMJ Publishing Group

58 George W Bush ldquoPresident Discusses Stem Cell Researchrdquo Office of the Press Secretary White House August 9 2001

59 Jeff McMahan ldquoKilling Embryos for Stem Cell Researchrdquo pp 170ndash89 from Metaphilosophy 38 23 (2007) Reproduced with permission from John Wiley amp Sons

60 Immanuel Kant ldquoDuties towards Animalsrdquo pp 239ndash41 from Lectures on Ethics trans Louis Infield London Methuen 1930 Copyright 1930 Methuen reproduced by permission of Taylor amp Francis Books UK

61 Jeremy Bentham ldquoA Utilitarian Viewrdquo section XVIII IV from An Introduction to the Principles of Morals and Legislation First published c1820

62 Peter Singer ldquoAll Animals are Equalrdquo pp 103ndash16 from Philosophic Exchange 1 5 (1974) Center for Philosophic Exchange State University of New York Brockford NY 1974

63 R G Frey and Sir William Paton ldquoVivisection Morals and Medicine An Exchangerdquo pp 94ndash7 and 102ndash4 from Journal of Medical Ethics 9 (1983) Reproduced with permission from BMJ Publishing Group

64 Michael J Selgelid ldquoEthics and Infectious Diseaserdquo pp 272ndash89 from Bioethics 19 3 (2005) Reproduced with permission from John Wiley amp Sons

65 Udo Schuumlklenk and Anita Kleinsmidt ldquoRethinking Mandatory HIV Testing during Pregnancy in Areas with High HIV Prevalence Rates Ethical and Policy Issuesrdquo pp 1179ndash83 from American Journal of Public Health 97 7 (2007) Reproduced with permission from American Public Health Association

66 Russell Armstrong ldquoMandatory HIV Testing in Pregnancy Is There Ever a Timerdquo pp 1ndash10 from Developing World Bioethics 8 1 (2008) Reproduced with permission from John Wiley amp Sons

67 Jerome Amir Singh Ross Upshur and Nesri Padayatchi ldquoXDR‐TB in South Africa No Time for Denial or Complacencyrdquo PLoS Med 4 1 (2007) e50 doi101371journalpmed0040050 Copyright copy 2007 Singh et al

xvi acknowledgments

68 Mark Siegler ldquoConfidentiality in Medicine A Decrepit Conceptrdquo pp 1518ndash21 from New England Journal of Medicine 307 24 (December 1982) Copyright copy 1982 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

69 Christian Saumlfken and Andreas Frewer ldquoThe Duty to Warn and Clinical Ethics Legal and Ethical Aspects of Confidentiality and HIVAIDSrdquo pp 313ndash326 from HEC Forum 19 4 (2007) With kind permission from Springer Science+Business Media

70 Immanuel Kant ldquoOn a Supposed Right to Lie from Altruistic Motivesrdquo pp 361ndash3 from Critique of Practical Reason and Other Works on the Theory of Ethics 6th edition trans T K Abbott London 1909 This essay was first published in a Berlin periodical in 1797

71 Joseph Collins ldquoShould Doctors Tell the Truthrdquo pp 320ndash6 from Harperrsquos Monthly Magazine 155 (August 1927) Copyright copy 1927 Harperrsquos Magazine All rights reserved Reproduced from the August issue by special permission

72 Roger Higgs ldquoOn Telling Patients the Truthrdquo pp 186ndash202 and 232ndash3 from Michael Lockwood (ed) Moral Dilemmas in Modern Medicine Oxford Oxford University Press 1985 By permission of Oxford University Press

73 John Stuart Mill ldquoOn Libertyrdquo first published in 1859

74 Justice Benjamin N Cardozo Judgment from Schloendorff v New York Hospital (1914) p 526 from Jay Katz (ed) Experimentation with Human Beings The Authority of the Investigator Subject Professions and State in the Human Experimentation Process New York Russell Sage Foundation 1972 Reproduced with permission of Russell Sage Foundation

75 Tom L Beauchamp ldquoInformed Consent Its History Meaning and Present Challengesrdquo pp 515ndash23 from Cambridge Quarterly of Health Care Ethics 20 4 (2011) copy Royal Institute of Philosophy published by Cambridge University Press Reproduced with permission from Cambridge University Press and T Beauchamp

76 Ruth Macklin ldquoThe DoctorndashPatient Relationshyship in Different Culturesrdquo pp 86ndash107 from

Against Relativism Cultural Diversity and the Search of Ethical Universals in Medicine copy 1999 by Oxford University Press Inc By permission of Oxford University Press USA

77 Carl Elliott ldquoAmputees by Choicerdquo pp 208ndash10 210ndash15 219ndash23 227ndash31 234ndash6 323ndash6 from Better Than Well American Medicine Meets the American Dream New York and London WW Norton 2003 Copyright copy 2003 by Carl Elliott Used by permission of W W Norton amp Company Inc

78 Julian Savulescu ldquoRational Desires and the Limishytation of Life‐Sustaining Treatmentrdquo pp 191ndash 222 from Bioethics 8 3 (1994) Reproduced with permission from John Wiley amp Sons

79 Shlomo Cohen ldquoThe Nocebo Effect of Informed Consentrdquo pp 147ndash54 from Bioethics 28 3 (2014) Reproduced with permission from John Wiley amp Sons

80 Sarah E Dock ldquoThe Relation of the Nurse to the Doctor and the Doctor to the Nurserdquo p 394 (extract) from The American Journal of Nursing 17 5 (1917)

81 Lisa H Newton ldquoIn Defense of the Traditional Nurserdquo pp 348ndash54 from Nursing Outlook 29 6 (1981) Copyright Elsevier 1981

82 Sarah Breier ldquoPatient Autonomy and Medical Paternity Can Nurses Help Doctors to Listen to Patientsrdquo pp 510ndash21 from Nursing Ethics 8 6 (2001) Reproduced with permission from Sage and S Breier

83 Carol Pavlish Anita Ho and Ann‐Marie Rounkle ldquoHealth and Human Rights Advocacy Perspectives from a Rwandan Refugee Camprdquo pp 538ndash49 from Nursing Ethics 19 4 (2012) Copyright copy 2012 by SAGE Publications Reprinted by Permission of SAGE

84 Jonathan D Moreno ldquoNeuroethics An Agenda for Neuroscience and Societyrdquo pp 149ndash53 from Nature Reviews 4 (February 2003)Reprinted by permission from Macmillan Publishers Ltd

85 Sally Adee ldquoHow Electrical Brain Stimulation Can Change the Way We Thinkrdquo The Week March 30 2012

86 Neil Levy ldquoNeuroethics Ethics and the Sciences of the Mindrdquo pp 69ndash74 (extract) from Philosophy

Acknowledgments xvii

Compass 4 10 (2009) pp 69ndash81 Reproduced with permission from John Wiley amp Sons

87 Adam Kolber ldquoFreedom of Memory Todayrdquo pp 145ndash8 from Neuroethics 1 (2008) With kind permission from Springer Science+Business Media

88 Henry Greely and Colleagues ldquoTowards Responsible Use of Cognitive‐Enhancing Drugs

by the Healthyrdquo pp 702ndash5 from Nature 456 (December 11 2008) Reprinted by permission from Macmillan Publishers Ltd

89 Julian Savulescu and Anders Sandberg ldquoEngineering LoverdquoldquoLove Machine Engineering Lifelong Romancerdquo pp 28ndash9 from New Scientist 2864 copy 2012 Reed Business Information ndash UK All rights reserved Distributed by Tribune Content Agency

Bioethics An Anthology Third Edition Edited by Helga Kuhse Udo Schuumlklenk and Peter Singer copy 2016 John Wiley amp Sons Inc Published 2016 by John Wiley amp Sons Inc

Introduction

The term ldquobioethicsrdquo was coined by Van Rensselaer Potter who used it to describe his proposal that we need an ethic that can incorporate our obligations not just to other humans but to the biosphere as a whole1 Although the term is still occasionally used in this sense of an ecological ethic it is now much more commonly used in the narrower sense of the study of ethical issues arising from the biological and medical sciences So understood bioethics has become a specialized although interdisciplinary area of study The essays included in this book give an indication of the range of issues which fall within its scope ndash but it is only an indication There are many other issues that we simply have not had the space to cover

Bioethics can be seen as a branch of ethics or more specifically of applied ethics For this reason some understanding of the nature of ethics is an essential preliminary to any serious study of bioethics The remainder of this introduction will seek to provide that understanding

One question about the nature of ethics is especially relevant to bioethics to what extent is reasoning or argument possible in ethics Many people assume without much thought that ethics is subjective The subjectivist holds that what ethical view we take is a matter of opinion or taste that is not amenable to argument But if ethics were a matter of taste why would we even attempt to argue about it If Helen says ldquoI like my coffee sweetenedrdquo whereas Paul says

ldquoI like my coffee unsweetenedrdquo there is not much point in Helen and Paul arguing about it The two statements do not contradict each other They can both be true But if Helen says ldquoDoctors should never assist their patients to dierdquo whereas Paul says ldquoSometimes doctors should assist their patients to dierdquo then Helen and Paul are disagreeing and there does seem to be a point in their trying to argue about the issue of physician‐assisted suicide

It seems clear that there is some scope for argument in ethics If I say ldquoIt is always wrong to kill a human beingrdquo and ldquoAbortion is not always wrongrdquo then I am committed to denying that abortion kills a human being Otherwise I have contradicted myself and in doing so I have not stated a coherent position at all So consistency at least is a requirement of any defensible ethical position and thus sets a limit to the subjectivity of ethical judgments The requirement of factual accuracy sets another limit In discussing issues in bioethics the facts are often complex But we cannot reach the right ethical decisions unless we are well‐informed about the relevant facts In this respect ethical decisions are unlike decisions of taste We can enjoy a taste without knowing what we are eating but if we assume that it is wrong to resuscitate a terminally ill patient against her wishes then we can-not know whether an instance of resuscitation was morally right or wrong without knowing something about the patientrsquos prognosis and whether the patient

2 introduction

has expressed any wishes about being resuscitated In that sense there is no equivalent in ethics to the immediacy of taste

Ethical relativism sometimes also known as cul-tural relativism is one step away from ethical sub-jectivism but it also severely limits the scope of ethical argument The ethical relativist holds that it is not individual attitudes that determine what is right or wrong but the attitudes of the culture in which one lives Herodotus tells how Darius King of Persia summoned the Greeks from the western shores of his kingdom before him and asked them how much he would have to pay them to eat their fathersrsquo dead bodies They were horrified by the idea and said they would not do it for any amount of money for it was their custom to cremate their dead Then Darius called upon Indians from the eastern frontiers of his kingdom and asked them what would make them willing to burn their fathersrsquo bodies They cried out and asked the King to refrain from mentioning so shocking an act Herodotus comments that each nation thinks its own customs best From here it is only a short step to the view that there can be no objective right or wrong beyond the bounds of onersquos own culture This view found increased support in the nine-teenth century as Western anthropologists came to know many different cultures and were impressed by ethical views very different from those that were standardly taken for granted in European society As a defense against the automatic assumption that Western morality is superior and should be imposed on ldquosavagesrdquo many anthropologists argued that since morality is relative to culture no culture can have any basis for regarding its morality as superior to any other culture

Although the motives with which anthropolo-gists put this view forward were admirable they may not have appreciated the implications of the position they were taking The ethical relativist maintains that a statement like ldquoIt is good to enslave people from another tribe if they are captured in warrdquo means simply ldquoIn my society the custom is to enslave people from another tribe if they are cap-tured in warrdquo Hence if one member of the society were to question whether it really was good to enslave people in these circumstances she could be

answered simply by demonstrating that this was indeed the custom ndash for example by showing that for many generations it had been done after every war in which prisoners were captured Thus there is no way for moral reformers to say that an accepted custom is wrong ndash ldquowrongrdquo just means ldquoin accord-ance with an accepted customrdquo

On the other hand when people from two different cultures disagree about an ethical issue then according to the ethical relativist there can be no resolution of the disagreement Indeed strictly there is no disagree-ment If the apparent dispute were over the issue just mentioned then one person would be saying ldquoIn my country it is the custom to enslave people from another tribe if they are captured in warrdquo and the other person would be saying ldquoIn my country it is not the custom to allow one human being to enslave anotherrdquo This is no more a disagreement than such statements as ldquoIn my country people greet each other by rubbing nosesrdquo and ldquoIn my country people greet each other by shaking handsrdquo If ethical relativism is true then it is impossible to say that one culture is right and the other is wrong Bearing in mind that some cultures have practiced slavery or the burning of widows on the funeral pyre of their husbands this is hard to accept

A more promising alternative to both ethical subjectivism and cultural relativism is universal pre-scriptivism an approach to ethics developed by the Oxford philosopher R M Hare Hare argues that the distinctive property of ethical judgments is that they are universalizable In saying this he means that if I make an ethical judgment I must be prepared to state it in universal terms and apply it to all relevantly similar situations By ldquouniversal termsrdquo Hare means those terms that do not refer to a particular individual Thus a proper name cannot be a universal term If for example I were to say ldquoEveryone should do what is in the interests of Mick Jaggerrdquo I would not be making a universal judgment because I have used a proper name The same would be true if I were to say that everyone must do what is in my interests because the personal pronoun ldquomyrdquo is here used to refer to a particular individual myself

It might seem that ruling out particular terms in this way does not take us very far After all one can always describe oneself in universal terms Perhaps

Introduction 3

I canrsquot say that everyone should do what is in my interests but I could say that everyone must do whatever is in the interests of people who hellip and then give a minutely detailed description of myself including the precise location of all my freckles The effect would be the same as saying that everyone should do what is in my interests because there would be no one except me who matches that description But Hare meets this problem very effectively by saying that to prescribe an ethical judgment universally means being prepared to pre-scribe it for all possible circumstances including hypothetical ones So if I were to say that everyone should do what is in the interests of a person with a particular pattern of freckles I must be prepared to prescribe that in the hypothetical situation in which I do not have this pattern of freckles but someone else does I should do what is in the interests of that person Now of course I may say that I should do that since I am confident that I shall never be in such a situation but this simply means that I am being dishonest I am not genuinely prescribing the principle universally

The effect of saying that an ethical judgment must be universalizable for hypothetical as well as actual circumstances is that whenever I make an ethical judgment I can be challenged to put myself in the position of the parties affected and see if I would still be able to accept that judgment Suppose for example that I own a small factory and the cheapest way for me to get rid of some waste is to pour it into a nearby river I do not take water from this river but I know that some villagers living downstream do and the waste may make them ill The requirement that ethical judgments should be universalizable will make it difficult for me to justify my conduct because if I imagine myself in the hypothetical situation of being one of the villagers rather than the factory‐owner I would not accept that the profits of the factory‐owner should outweigh the risk of adverse effects on my health and that of my children In this way Harersquos approach requires us to take into account the interests and preferences of all others affected by our actions Hence it allows for an element of reasoning in ethical deliberation

Since the rightness or wrongness of our actions will on this view depend on the way in which they

affect others Harersquos universal prescriptivism leads to a form of consequentialism ndash that is the view that the rightness of an action depends on its consequences The best‐known form of consequentialism is the clas-sical utilitarianism developed in the late eighteenth century by Jeremy Bentham and popularized in the nineteenth century by John Stuart Mill They held that an action is right if it leads to a greater surplus of happiness over misery than any possible alternative and wrong if it does not By ldquogreater surplus of happinessrdquo the classical utilitarians had in mind the idea of adding up all the pleasure or happiness that resulted from the action and subtracting from that total all the pain or misery to which the action gave rise Naturally in some circumstances it might be possible only to reduce misery and then the right action should be understood as the one that will result in less misery than any possible alternative

The utilitarian view is striking in many ways It puts forward a single principle that it claims can provide the right answer to all ethical dilemmas if only we can predict what the consequences of our actions will be It takes ethics out of the mysterious realm of duties and rules and bases ethical decisions on something that almost everyone understands and values Moreover utilitarianismrsquos single principle is applied universally without fear or favor Bentham said ldquoEach to count for one and none for more than onerdquo by which he meant that the happiness of a com-mon tramp counted for as much as that of a noble and the happiness of an African was no less important than that of a European

Many contemporary consequentialists agree with Bentham to the extent that they think the rightness or wrongness of an action must depend on its conse-quences but they have abandoned the idea that m aximizing net happiness is the ultimate goal Instead they argue that we should seek to bring about w hatever will satisfy the greatest number of desires or preference This variation which is known as ldquop reference utilitarianismrdquo does not regard anything as good except in so far as it is wanted or desired More intense or strongly held preferences would get more weight than weak preferences

Consequentialism offers one important answer to the question of how we should decide what is right and what is wrong but many ethicists reject it The

4 introduction

denial of this view was dramatically presented by Dostoevsky in The Karamazov Brothers

imagine that you are charged with building the edifice of human destiny the ultimate aim of which is to bring people happiness to give them peace and contentment at last but that in order to achieve this it is essential and unavoidable to torture just one little speck of creation that same little child beating her chest with her little fists and imagine that this edifice has to be erected on her unexpiated tears Would you agree to be the architect under those conditions Tell me honestly2

The passage suggests that some things are always wrong no matter what their consequences This has for most of Western history been the prevailing approach to morality at least at the level of what has been officially taught and approved by the institutions of Church and State The ten commandments of the Hebrew scriptures served as a model for much of the Christian era and the Roman Catholic Church built up an elaborate system of morality based on rules to which no exceptions were allowed

Another example of an ethic of rules is that of Immanuel Kant Kantrsquos ethic is based on his ldquocategori-cal imperativerdquo which he states in several distinct for-mulations One is that we must always act so that we can will the maxim of our action to be a universal law This can be interpreted as a form of Harersquos idea of universalizability which we have already encountered Another is that we must always treat other people as ends never as means While these formulations of the categorical imperative might be applied in various ways in Kantrsquos hands they lead to inviolable rules for example against making promises that we do not intend to keep Kant also thought that it was always wrong to tell a lie In response to a critic who sug-gested that this rule has exceptions Kant said that it would be wrong to lie even if someone had taken refuge in your house and a person seeking to murder him came to your door and asked if you knew where he was Modern Kantians often reject this hard-line approach to rules and claim that Kantrsquos categorical imperative did not require him to hold so strictly to the rule against lying

How would a consequentialist ndash for example a classical utilitarian ndash answer Dostoevskyrsquos challenge If answering honestly ndash and if one really could be certain

that this was a sure way and the only way of bringing lasting happiness to all the people of the world ndash utilitarians would have to say yes they would accept the task of being the architect of the happiness of the world at the cost of the childrsquos unexpiated tears For they would point out that the suffering of that child wholly undeserved as it is will be repeated a million‐fold over the next century for other children just as innocent who are victims of starvation disease and brutality So if this one child must be sacrificed to stop all this suffering then terrible as it is the child must be sacrificed

Fantasy apart there can be no architect of the hap-piness of the world The world is too big and complex a place for that But we may attempt to bring about less suffering and more happiness or satisfaction of preferences for people or sentient beings in specific places and circumstances Alternatively we might fol-low a set of principles or rules ndash which could be of varying degrees of rigidity or flexibility Where would such rules come from Kant tried to deduce them from his categorical imperative which in turn he had reached by insisting that the moral law must be based on reason alone without any content from our wants or desires But the problem with trying to deduce morality from reason alone has always been that it becomes an empty formalism that cannot tell us what to do To make it practical it needs to have some addi-tional content and Kantrsquos own attempts to deduce rules of conduct from his categorical imperative are unconvincing

Others following Aristotle have tried to draw on human nature as a source of moral rules What is good they say is what is natural to human beings They then contend that it is natural and right for us to seek certain goods such as knowledge friendship health love and procreation and unnatural and wrong for us to act contrary to these goods This ldquonatural lawrdquo ethic is open to criticism on several points The word ldquonaturalrdquo can be used both descriptively and evalua-tively and the two senses are often mixed together so that value judgments may be smuggled in under the guise of a description The picture of human nature presented by proponents of natural law ethics usually selects only those characteristics of our nature that the proponent considers desirable The fact that our species especially its male members frequently go to war and

Introduction 5

are also prone to commit individual acts of violence against others is no doubt just as much part of our nature as our desire for knowledge but no natural law theorist therefore views these activities as good More generally natural law theory has its origins in an Aristotelian idea of the cosmos in which everything has a goal or ldquoendrdquo which can be deduced from its nature The ldquoendrdquo of a knife is to cut the assumption is that human beings also have an ldquoendrdquo and we will flourish when we live in accordance with the end for which we are suited But this is a pre‐Darwinian view of nature Since Darwin we know that we do not exist for any purpose but are the result of natural selection operating on random mutations over millions of years Hence there is no reason to believe that living accord-ing to nature will produce a harmonious society let alone the best possible state of affairs for human beings

Another way in which it has been claimed that we can come to know what moral principles or rules we should follow is through our intuition In practice this usually means that we adopt conven-tionally accepted moral principles or rules perhaps with some adjustments in order to avoid inconsist-ency or arbitrariness On this view a moral theory should like a scientific theory try to match the data and the data that a moral theory must match is p rovided by our moral intuitions As in science if a plausible theory matches most but not all of the data then the anomalous data might be rejected on the grounds that it is more likely that there was an error in the procedures for gathering that particular set of data than that the theory as a whole is mis-taken But ultimately the test of a theory is its ability to explain the data The problem with applying this model of scientific justification to ethics is that the ldquodatardquo of our moral intuitions is unreliable not just at one or two specific points but as a whole Here the facts that cultural relativists draw upon are rele-vant (even if they do not establish that cultural rela-tivism is the correct response to it) Since we know that our intuitions are strongly influenced by such things as culture and religion they are ill‐suited to serve as the fixed points against which an ethical theory must be tested Even where there is cross‐cultural agreement there may be some aspects of our intuitions on which all cultures unjustifiably favor our own interests over those of others For

example simply because we are all human beings we may have a systematic bias that leads us to give an unjustifiably low moral status to nonhuman a nimals Or because in virtually all known human societies men have taken a greater leadership role than women the moral intuitions of all societies may not adequately reflect the interests of females

Some philosophers think that it is a mistake to base ethics on principles or rules Instead they focus on what it is to be a good person ndash or in the case of the problems with which this book is concerned perhaps on what it is to be a good nurse or doctor or researcher They seek to describe the virtues that a good person or a good member of the relevant profession should possess Moral education then consists of teaching these virtues and discussing how a virtuous person would act in specific situations The question is how-ever whether we can have a notion of what a virtuous person would do in a specific situation without making a prior decision about what it is right to do After all in any particular moral dilemma different virtues may be applicable and even a particular virtue will not always give unequivocal guidance For instance if a terminally ill patient repeatedly asks a nurse or doctor for assistance in dying what response best exemplifies the virtues of a healthcare professional There seems no answer to this question short of an inquiry into whether it is right or wrong to help a patient in such circumstances to die But in that case we seem bound in the end to come back to discuss-ing such issues as whether it is right to follow moral rules or principles or to do what will have the best consequences

In the late twentieth century some feminists offered new criticisms of conventional thought about ethics They argued that the approaches to ethics taken by the influential philosophers of the past ndash all of whom have been male ndash give too much emphasis to abstract principles and the role of reason and give too little attention to personal relationships and the part played by emotion One outcome of these criticisms has been the development of an ldquoethic of carerdquo which is not so much a single ethical theory as a cluster of ways of looking at ethics which put an attitude of c aring for others at the center and seek to avoid r eliance on abstract ethical principles The ethic of care has seemed especially applicable to the work of those

6 introduction

involved in direct patient care and has recently been taken up by a number of nursing theorists as offering a more suitable alternative to other ideas of ethics Not all feminists however support this development Some worry that the adoption of a ldquocarerdquo approach by nurses may reflect and even reinforce stereotypes of women as more emotional and less rational than men They also fear that it could lead to women continuing to carry a disproportionate burden of caring for others to the exclusion of adequately caring for themselves

In this discussion of ethics we have not mentioned anything about religion This may seem odd in view of the close connection that has often been made between religion and ethics but it reflects our belief that despite this historical connection ethics and reli-gion are fundamentally independent Logically ethics is prior to religion If religious believers wish to say that a deity is good or praise her or his creation or deeds they must have a notion of goodness that is independent of their conception of the deity and what she or he does Otherwise they will be saying that the deity is good and when asked what they mean by ldquogoodrdquo they will have to refer back to the deity saying perhaps that ldquogoodrdquo means ldquoin accord-ance with the wishes of the deityrdquo In that case sen-tences such as ldquoGod is goodrdquo would be a meaningless tautology ldquoGod is goodrdquo could mean no more than ldquoGod is in accordance with Godrsquos wishesrdquo As we have already seen there are ideas of what it is for something to be ldquogoodrdquo that are not rooted in any religious belief While religions typically encourage or instruct their followers to obey a particular ethical code it is obvious that others who do not follow any religion can also think and act ethically

To say that ethics is independent of religion is not to deny that theologians or other religious believers may have a role to play in bioethics Religious traditions often have long histories of dealing with ethical dilem-mas and the accumulation of wisdom and experience that they represent can give us valuable insights into particular problems But these insights should be subject to criticism in the way that any other proposals would be If in the end we accept them it is because we have judged them sound not because they are the utterances of a pope a rabbi a mullah or a holy person

Ethics is also independent of the law in the sense that the rightness or wrongness of an act cannot be

settled by its legality or illegality Whether an act is legal or illegal may often be relevant to whether it is right or wrong because it is arguably wrong to break the law other things being equal Many people have thought that this is especially so in a democracy in which everyone has a say in making the law Another reason why the fact that an act is illegal may be a rea-son against doing it is that the legality of an act may affect the consequences that are likely to flow from it If active voluntary euthanasia is illegal then doctors who practice it risk going to jail which will cause them and their families to suffer and also mean that they will no longer be able to help other patients This can be a powerful reason for not practicing voluntary euthanasia when it is against the law but if there is only a very small chance of the offense becoming known or being proved then the weight of this con-sequentialist reason against breaking the law is reduced accordingly Whether we have an ethical obligation to obey the law and if so how much weight should be given to it is itself an issue for ethical argument

Though ethics is independent of the law in the sense just specified laws are subject to evaluation from an ethical perspective Many debates in bioethics focus on questions about what practices should be allowed ndash for example should we allow research on stem cells taken from human embryos sex selection or cloning ndash and committees set up to advise on the ethical social and legal aspects of these questions often recommend legislation to prohibit the activity in question or to allow it to be practiced under some form of regulation Discussing a question at the level of law and public policy however raises somewhat different considerations than a discussion of personal ethics because the consequences of adopting a public policy generally have much wider ramifications than the consequences of a personal choice That is why some healthcare professionals feel justified in assisting a terminally ill patient to die while at the same time opposing the legalization of physician‐assisted suicide Paradoxical as this position may appear ndash and it is certainly open to criticism ndash it is not straightforwardly inconsistent

Naturally many of the essays we have selected reflect the times in which they were written Since bioethics often comments on developments in fast‐moving

Introduction 7

areas of medicine and the biological sciences the factual content of articles in bioethics can become obsolete quite rapidly In preparing this revised edition we have taken the opportunity to cover some new issues and to include some more recent writings We have for example included new mate-rial on genetic enhancement as well as on the use of embryonic human stem cells This edition of the anthology also includes new sections on ethical issues in public health and in the neurosciences Nevertheless an article that has dated in regard to its facts often makes ethical points that are still valid

or worth considering so we have not excluded older articles for this reason

Other articles are dated in a different way During the past few decades we have become more sensitive about the ways in which our language may exclude women or reflect our prejudices regarding race or sexuality We see no merit in trying to disguise past practices on such matters so we have not excluded otherwise valuable works in bioethics on these grounds If they are jar-ring to the modern reader that may be a salutary reminder of the extent to which we all are subject to the conventions and prejudices of our times

Notes

1 See Van Rensselaer Potter Bioethics Bridge to the Future (Englewood Cliffs NJ Prentice‐Hall 1971)

2 The Karamazov Brothers trans Ignat Avsey (Oxford Oxford University Press 1994) vol I part 2 bk 5 ch 4 First published in 1879

Abortion

Part I

Acknowledgments xv

50 Henry K Beecher ldquoEthics and Clinical Researchrdquo pp 1354ndash60 from New England Journal of Medicine 274 24 (June 1966) Copyright copy 1996 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

51 Benjamin Freedman ldquoEquipoise and the Ethics of Clinical Researchrdquo pp 141ndash5 from New England Journal of Medicine 317 3 (July 1987) Copyright copy 1987 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

52 Samuel Hellman ldquoThe Patient and the Public Goodrdquo pp 400ndash2 from Nature Medicine 1 5 (1995) Reprinted by permission from Macmillan Publishers Ltd

53 John Harris ldquoScientific Research Is a Moral Dutyrdquo pp 242ndash8 from Journal of Medical Ethics 31 4 (2005) Reproduced with permission from BMJ Publishing Group

54 Sandra Shapshay and Kenneth D Pimple ldquoParticipation in Research Is an Imperfect Moral Duty A Response to John Harrisrdquo pp 414ndash17 from Journal of Medical Ethics 33 (2007) Reproduced with permission from BMJ Publishing Group

55 Peter Lurie and Sidney M Wolfe ldquoUnethical Trials of Interventions to Reduce Perinatal Transmission of the Human Immunodeficiency Virus in Developing Countriesrdquo pp 853ndash6 from New England Journal of Medicine 337 12 (September 1997) Copyright copy 1997 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

56 Danstan Bageda and Philippa Musoke‐Mudido ldquoWersquore Trying to Help Our Sickest People Not Exploit Themrdquo from The Washington Post September 28 1997 copy 1997 Washington Post Company All rights reserved Used by permisshysion and protected by the Copyright Laws of the United States The printing copying redistribushytion or retransmission of this Content without express written permission is prohibited

57 Leah Belsky and Henry S Richardson ldquoMedical Researchersrsquo Ancillary Clinical Care Respon sibilitiesrdquo pp 1494ndash6 from British

Medical Journal 328 (June 19 2004) Reproduced with permission from BMJ Publishing Group

58 George W Bush ldquoPresident Discusses Stem Cell Researchrdquo Office of the Press Secretary White House August 9 2001

59 Jeff McMahan ldquoKilling Embryos for Stem Cell Researchrdquo pp 170ndash89 from Metaphilosophy 38 23 (2007) Reproduced with permission from John Wiley amp Sons

60 Immanuel Kant ldquoDuties towards Animalsrdquo pp 239ndash41 from Lectures on Ethics trans Louis Infield London Methuen 1930 Copyright 1930 Methuen reproduced by permission of Taylor amp Francis Books UK

61 Jeremy Bentham ldquoA Utilitarian Viewrdquo section XVIII IV from An Introduction to the Principles of Morals and Legislation First published c1820

62 Peter Singer ldquoAll Animals are Equalrdquo pp 103ndash16 from Philosophic Exchange 1 5 (1974) Center for Philosophic Exchange State University of New York Brockford NY 1974

63 R G Frey and Sir William Paton ldquoVivisection Morals and Medicine An Exchangerdquo pp 94ndash7 and 102ndash4 from Journal of Medical Ethics 9 (1983) Reproduced with permission from BMJ Publishing Group

64 Michael J Selgelid ldquoEthics and Infectious Diseaserdquo pp 272ndash89 from Bioethics 19 3 (2005) Reproduced with permission from John Wiley amp Sons

65 Udo Schuumlklenk and Anita Kleinsmidt ldquoRethinking Mandatory HIV Testing during Pregnancy in Areas with High HIV Prevalence Rates Ethical and Policy Issuesrdquo pp 1179ndash83 from American Journal of Public Health 97 7 (2007) Reproduced with permission from American Public Health Association

66 Russell Armstrong ldquoMandatory HIV Testing in Pregnancy Is There Ever a Timerdquo pp 1ndash10 from Developing World Bioethics 8 1 (2008) Reproduced with permission from John Wiley amp Sons

67 Jerome Amir Singh Ross Upshur and Nesri Padayatchi ldquoXDR‐TB in South Africa No Time for Denial or Complacencyrdquo PLoS Med 4 1 (2007) e50 doi101371journalpmed0040050 Copyright copy 2007 Singh et al

xvi acknowledgments

68 Mark Siegler ldquoConfidentiality in Medicine A Decrepit Conceptrdquo pp 1518ndash21 from New England Journal of Medicine 307 24 (December 1982) Copyright copy 1982 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

69 Christian Saumlfken and Andreas Frewer ldquoThe Duty to Warn and Clinical Ethics Legal and Ethical Aspects of Confidentiality and HIVAIDSrdquo pp 313ndash326 from HEC Forum 19 4 (2007) With kind permission from Springer Science+Business Media

70 Immanuel Kant ldquoOn a Supposed Right to Lie from Altruistic Motivesrdquo pp 361ndash3 from Critique of Practical Reason and Other Works on the Theory of Ethics 6th edition trans T K Abbott London 1909 This essay was first published in a Berlin periodical in 1797

71 Joseph Collins ldquoShould Doctors Tell the Truthrdquo pp 320ndash6 from Harperrsquos Monthly Magazine 155 (August 1927) Copyright copy 1927 Harperrsquos Magazine All rights reserved Reproduced from the August issue by special permission

72 Roger Higgs ldquoOn Telling Patients the Truthrdquo pp 186ndash202 and 232ndash3 from Michael Lockwood (ed) Moral Dilemmas in Modern Medicine Oxford Oxford University Press 1985 By permission of Oxford University Press

73 John Stuart Mill ldquoOn Libertyrdquo first published in 1859

74 Justice Benjamin N Cardozo Judgment from Schloendorff v New York Hospital (1914) p 526 from Jay Katz (ed) Experimentation with Human Beings The Authority of the Investigator Subject Professions and State in the Human Experimentation Process New York Russell Sage Foundation 1972 Reproduced with permission of Russell Sage Foundation

75 Tom L Beauchamp ldquoInformed Consent Its History Meaning and Present Challengesrdquo pp 515ndash23 from Cambridge Quarterly of Health Care Ethics 20 4 (2011) copy Royal Institute of Philosophy published by Cambridge University Press Reproduced with permission from Cambridge University Press and T Beauchamp

76 Ruth Macklin ldquoThe DoctorndashPatient Relationshyship in Different Culturesrdquo pp 86ndash107 from

Against Relativism Cultural Diversity and the Search of Ethical Universals in Medicine copy 1999 by Oxford University Press Inc By permission of Oxford University Press USA

77 Carl Elliott ldquoAmputees by Choicerdquo pp 208ndash10 210ndash15 219ndash23 227ndash31 234ndash6 323ndash6 from Better Than Well American Medicine Meets the American Dream New York and London WW Norton 2003 Copyright copy 2003 by Carl Elliott Used by permission of W W Norton amp Company Inc

78 Julian Savulescu ldquoRational Desires and the Limishytation of Life‐Sustaining Treatmentrdquo pp 191ndash 222 from Bioethics 8 3 (1994) Reproduced with permission from John Wiley amp Sons

79 Shlomo Cohen ldquoThe Nocebo Effect of Informed Consentrdquo pp 147ndash54 from Bioethics 28 3 (2014) Reproduced with permission from John Wiley amp Sons

80 Sarah E Dock ldquoThe Relation of the Nurse to the Doctor and the Doctor to the Nurserdquo p 394 (extract) from The American Journal of Nursing 17 5 (1917)

81 Lisa H Newton ldquoIn Defense of the Traditional Nurserdquo pp 348ndash54 from Nursing Outlook 29 6 (1981) Copyright Elsevier 1981

82 Sarah Breier ldquoPatient Autonomy and Medical Paternity Can Nurses Help Doctors to Listen to Patientsrdquo pp 510ndash21 from Nursing Ethics 8 6 (2001) Reproduced with permission from Sage and S Breier

83 Carol Pavlish Anita Ho and Ann‐Marie Rounkle ldquoHealth and Human Rights Advocacy Perspectives from a Rwandan Refugee Camprdquo pp 538ndash49 from Nursing Ethics 19 4 (2012) Copyright copy 2012 by SAGE Publications Reprinted by Permission of SAGE

84 Jonathan D Moreno ldquoNeuroethics An Agenda for Neuroscience and Societyrdquo pp 149ndash53 from Nature Reviews 4 (February 2003)Reprinted by permission from Macmillan Publishers Ltd

85 Sally Adee ldquoHow Electrical Brain Stimulation Can Change the Way We Thinkrdquo The Week March 30 2012

86 Neil Levy ldquoNeuroethics Ethics and the Sciences of the Mindrdquo pp 69ndash74 (extract) from Philosophy

Acknowledgments xvii

Compass 4 10 (2009) pp 69ndash81 Reproduced with permission from John Wiley amp Sons

87 Adam Kolber ldquoFreedom of Memory Todayrdquo pp 145ndash8 from Neuroethics 1 (2008) With kind permission from Springer Science+Business Media

88 Henry Greely and Colleagues ldquoTowards Responsible Use of Cognitive‐Enhancing Drugs

by the Healthyrdquo pp 702ndash5 from Nature 456 (December 11 2008) Reprinted by permission from Macmillan Publishers Ltd

89 Julian Savulescu and Anders Sandberg ldquoEngineering LoverdquoldquoLove Machine Engineering Lifelong Romancerdquo pp 28ndash9 from New Scientist 2864 copy 2012 Reed Business Information ndash UK All rights reserved Distributed by Tribune Content Agency

Bioethics An Anthology Third Edition Edited by Helga Kuhse Udo Schuumlklenk and Peter Singer copy 2016 John Wiley amp Sons Inc Published 2016 by John Wiley amp Sons Inc

Introduction

The term ldquobioethicsrdquo was coined by Van Rensselaer Potter who used it to describe his proposal that we need an ethic that can incorporate our obligations not just to other humans but to the biosphere as a whole1 Although the term is still occasionally used in this sense of an ecological ethic it is now much more commonly used in the narrower sense of the study of ethical issues arising from the biological and medical sciences So understood bioethics has become a specialized although interdisciplinary area of study The essays included in this book give an indication of the range of issues which fall within its scope ndash but it is only an indication There are many other issues that we simply have not had the space to cover

Bioethics can be seen as a branch of ethics or more specifically of applied ethics For this reason some understanding of the nature of ethics is an essential preliminary to any serious study of bioethics The remainder of this introduction will seek to provide that understanding

One question about the nature of ethics is especially relevant to bioethics to what extent is reasoning or argument possible in ethics Many people assume without much thought that ethics is subjective The subjectivist holds that what ethical view we take is a matter of opinion or taste that is not amenable to argument But if ethics were a matter of taste why would we even attempt to argue about it If Helen says ldquoI like my coffee sweetenedrdquo whereas Paul says

ldquoI like my coffee unsweetenedrdquo there is not much point in Helen and Paul arguing about it The two statements do not contradict each other They can both be true But if Helen says ldquoDoctors should never assist their patients to dierdquo whereas Paul says ldquoSometimes doctors should assist their patients to dierdquo then Helen and Paul are disagreeing and there does seem to be a point in their trying to argue about the issue of physician‐assisted suicide

It seems clear that there is some scope for argument in ethics If I say ldquoIt is always wrong to kill a human beingrdquo and ldquoAbortion is not always wrongrdquo then I am committed to denying that abortion kills a human being Otherwise I have contradicted myself and in doing so I have not stated a coherent position at all So consistency at least is a requirement of any defensible ethical position and thus sets a limit to the subjectivity of ethical judgments The requirement of factual accuracy sets another limit In discussing issues in bioethics the facts are often complex But we cannot reach the right ethical decisions unless we are well‐informed about the relevant facts In this respect ethical decisions are unlike decisions of taste We can enjoy a taste without knowing what we are eating but if we assume that it is wrong to resuscitate a terminally ill patient against her wishes then we can-not know whether an instance of resuscitation was morally right or wrong without knowing something about the patientrsquos prognosis and whether the patient

2 introduction

has expressed any wishes about being resuscitated In that sense there is no equivalent in ethics to the immediacy of taste

Ethical relativism sometimes also known as cul-tural relativism is one step away from ethical sub-jectivism but it also severely limits the scope of ethical argument The ethical relativist holds that it is not individual attitudes that determine what is right or wrong but the attitudes of the culture in which one lives Herodotus tells how Darius King of Persia summoned the Greeks from the western shores of his kingdom before him and asked them how much he would have to pay them to eat their fathersrsquo dead bodies They were horrified by the idea and said they would not do it for any amount of money for it was their custom to cremate their dead Then Darius called upon Indians from the eastern frontiers of his kingdom and asked them what would make them willing to burn their fathersrsquo bodies They cried out and asked the King to refrain from mentioning so shocking an act Herodotus comments that each nation thinks its own customs best From here it is only a short step to the view that there can be no objective right or wrong beyond the bounds of onersquos own culture This view found increased support in the nine-teenth century as Western anthropologists came to know many different cultures and were impressed by ethical views very different from those that were standardly taken for granted in European society As a defense against the automatic assumption that Western morality is superior and should be imposed on ldquosavagesrdquo many anthropologists argued that since morality is relative to culture no culture can have any basis for regarding its morality as superior to any other culture

Although the motives with which anthropolo-gists put this view forward were admirable they may not have appreciated the implications of the position they were taking The ethical relativist maintains that a statement like ldquoIt is good to enslave people from another tribe if they are captured in warrdquo means simply ldquoIn my society the custom is to enslave people from another tribe if they are cap-tured in warrdquo Hence if one member of the society were to question whether it really was good to enslave people in these circumstances she could be

answered simply by demonstrating that this was indeed the custom ndash for example by showing that for many generations it had been done after every war in which prisoners were captured Thus there is no way for moral reformers to say that an accepted custom is wrong ndash ldquowrongrdquo just means ldquoin accord-ance with an accepted customrdquo

On the other hand when people from two different cultures disagree about an ethical issue then according to the ethical relativist there can be no resolution of the disagreement Indeed strictly there is no disagree-ment If the apparent dispute were over the issue just mentioned then one person would be saying ldquoIn my country it is the custom to enslave people from another tribe if they are captured in warrdquo and the other person would be saying ldquoIn my country it is not the custom to allow one human being to enslave anotherrdquo This is no more a disagreement than such statements as ldquoIn my country people greet each other by rubbing nosesrdquo and ldquoIn my country people greet each other by shaking handsrdquo If ethical relativism is true then it is impossible to say that one culture is right and the other is wrong Bearing in mind that some cultures have practiced slavery or the burning of widows on the funeral pyre of their husbands this is hard to accept

A more promising alternative to both ethical subjectivism and cultural relativism is universal pre-scriptivism an approach to ethics developed by the Oxford philosopher R M Hare Hare argues that the distinctive property of ethical judgments is that they are universalizable In saying this he means that if I make an ethical judgment I must be prepared to state it in universal terms and apply it to all relevantly similar situations By ldquouniversal termsrdquo Hare means those terms that do not refer to a particular individual Thus a proper name cannot be a universal term If for example I were to say ldquoEveryone should do what is in the interests of Mick Jaggerrdquo I would not be making a universal judgment because I have used a proper name The same would be true if I were to say that everyone must do what is in my interests because the personal pronoun ldquomyrdquo is here used to refer to a particular individual myself

It might seem that ruling out particular terms in this way does not take us very far After all one can always describe oneself in universal terms Perhaps

Introduction 3

I canrsquot say that everyone should do what is in my interests but I could say that everyone must do whatever is in the interests of people who hellip and then give a minutely detailed description of myself including the precise location of all my freckles The effect would be the same as saying that everyone should do what is in my interests because there would be no one except me who matches that description But Hare meets this problem very effectively by saying that to prescribe an ethical judgment universally means being prepared to pre-scribe it for all possible circumstances including hypothetical ones So if I were to say that everyone should do what is in the interests of a person with a particular pattern of freckles I must be prepared to prescribe that in the hypothetical situation in which I do not have this pattern of freckles but someone else does I should do what is in the interests of that person Now of course I may say that I should do that since I am confident that I shall never be in such a situation but this simply means that I am being dishonest I am not genuinely prescribing the principle universally

The effect of saying that an ethical judgment must be universalizable for hypothetical as well as actual circumstances is that whenever I make an ethical judgment I can be challenged to put myself in the position of the parties affected and see if I would still be able to accept that judgment Suppose for example that I own a small factory and the cheapest way for me to get rid of some waste is to pour it into a nearby river I do not take water from this river but I know that some villagers living downstream do and the waste may make them ill The requirement that ethical judgments should be universalizable will make it difficult for me to justify my conduct because if I imagine myself in the hypothetical situation of being one of the villagers rather than the factory‐owner I would not accept that the profits of the factory‐owner should outweigh the risk of adverse effects on my health and that of my children In this way Harersquos approach requires us to take into account the interests and preferences of all others affected by our actions Hence it allows for an element of reasoning in ethical deliberation

Since the rightness or wrongness of our actions will on this view depend on the way in which they

affect others Harersquos universal prescriptivism leads to a form of consequentialism ndash that is the view that the rightness of an action depends on its consequences The best‐known form of consequentialism is the clas-sical utilitarianism developed in the late eighteenth century by Jeremy Bentham and popularized in the nineteenth century by John Stuart Mill They held that an action is right if it leads to a greater surplus of happiness over misery than any possible alternative and wrong if it does not By ldquogreater surplus of happinessrdquo the classical utilitarians had in mind the idea of adding up all the pleasure or happiness that resulted from the action and subtracting from that total all the pain or misery to which the action gave rise Naturally in some circumstances it might be possible only to reduce misery and then the right action should be understood as the one that will result in less misery than any possible alternative

The utilitarian view is striking in many ways It puts forward a single principle that it claims can provide the right answer to all ethical dilemmas if only we can predict what the consequences of our actions will be It takes ethics out of the mysterious realm of duties and rules and bases ethical decisions on something that almost everyone understands and values Moreover utilitarianismrsquos single principle is applied universally without fear or favor Bentham said ldquoEach to count for one and none for more than onerdquo by which he meant that the happiness of a com-mon tramp counted for as much as that of a noble and the happiness of an African was no less important than that of a European

Many contemporary consequentialists agree with Bentham to the extent that they think the rightness or wrongness of an action must depend on its conse-quences but they have abandoned the idea that m aximizing net happiness is the ultimate goal Instead they argue that we should seek to bring about w hatever will satisfy the greatest number of desires or preference This variation which is known as ldquop reference utilitarianismrdquo does not regard anything as good except in so far as it is wanted or desired More intense or strongly held preferences would get more weight than weak preferences

Consequentialism offers one important answer to the question of how we should decide what is right and what is wrong but many ethicists reject it The

4 introduction

denial of this view was dramatically presented by Dostoevsky in The Karamazov Brothers

imagine that you are charged with building the edifice of human destiny the ultimate aim of which is to bring people happiness to give them peace and contentment at last but that in order to achieve this it is essential and unavoidable to torture just one little speck of creation that same little child beating her chest with her little fists and imagine that this edifice has to be erected on her unexpiated tears Would you agree to be the architect under those conditions Tell me honestly2

The passage suggests that some things are always wrong no matter what their consequences This has for most of Western history been the prevailing approach to morality at least at the level of what has been officially taught and approved by the institutions of Church and State The ten commandments of the Hebrew scriptures served as a model for much of the Christian era and the Roman Catholic Church built up an elaborate system of morality based on rules to which no exceptions were allowed

Another example of an ethic of rules is that of Immanuel Kant Kantrsquos ethic is based on his ldquocategori-cal imperativerdquo which he states in several distinct for-mulations One is that we must always act so that we can will the maxim of our action to be a universal law This can be interpreted as a form of Harersquos idea of universalizability which we have already encountered Another is that we must always treat other people as ends never as means While these formulations of the categorical imperative might be applied in various ways in Kantrsquos hands they lead to inviolable rules for example against making promises that we do not intend to keep Kant also thought that it was always wrong to tell a lie In response to a critic who sug-gested that this rule has exceptions Kant said that it would be wrong to lie even if someone had taken refuge in your house and a person seeking to murder him came to your door and asked if you knew where he was Modern Kantians often reject this hard-line approach to rules and claim that Kantrsquos categorical imperative did not require him to hold so strictly to the rule against lying

How would a consequentialist ndash for example a classical utilitarian ndash answer Dostoevskyrsquos challenge If answering honestly ndash and if one really could be certain

that this was a sure way and the only way of bringing lasting happiness to all the people of the world ndash utilitarians would have to say yes they would accept the task of being the architect of the happiness of the world at the cost of the childrsquos unexpiated tears For they would point out that the suffering of that child wholly undeserved as it is will be repeated a million‐fold over the next century for other children just as innocent who are victims of starvation disease and brutality So if this one child must be sacrificed to stop all this suffering then terrible as it is the child must be sacrificed

Fantasy apart there can be no architect of the hap-piness of the world The world is too big and complex a place for that But we may attempt to bring about less suffering and more happiness or satisfaction of preferences for people or sentient beings in specific places and circumstances Alternatively we might fol-low a set of principles or rules ndash which could be of varying degrees of rigidity or flexibility Where would such rules come from Kant tried to deduce them from his categorical imperative which in turn he had reached by insisting that the moral law must be based on reason alone without any content from our wants or desires But the problem with trying to deduce morality from reason alone has always been that it becomes an empty formalism that cannot tell us what to do To make it practical it needs to have some addi-tional content and Kantrsquos own attempts to deduce rules of conduct from his categorical imperative are unconvincing

Others following Aristotle have tried to draw on human nature as a source of moral rules What is good they say is what is natural to human beings They then contend that it is natural and right for us to seek certain goods such as knowledge friendship health love and procreation and unnatural and wrong for us to act contrary to these goods This ldquonatural lawrdquo ethic is open to criticism on several points The word ldquonaturalrdquo can be used both descriptively and evalua-tively and the two senses are often mixed together so that value judgments may be smuggled in under the guise of a description The picture of human nature presented by proponents of natural law ethics usually selects only those characteristics of our nature that the proponent considers desirable The fact that our species especially its male members frequently go to war and

Introduction 5

are also prone to commit individual acts of violence against others is no doubt just as much part of our nature as our desire for knowledge but no natural law theorist therefore views these activities as good More generally natural law theory has its origins in an Aristotelian idea of the cosmos in which everything has a goal or ldquoendrdquo which can be deduced from its nature The ldquoendrdquo of a knife is to cut the assumption is that human beings also have an ldquoendrdquo and we will flourish when we live in accordance with the end for which we are suited But this is a pre‐Darwinian view of nature Since Darwin we know that we do not exist for any purpose but are the result of natural selection operating on random mutations over millions of years Hence there is no reason to believe that living accord-ing to nature will produce a harmonious society let alone the best possible state of affairs for human beings

Another way in which it has been claimed that we can come to know what moral principles or rules we should follow is through our intuition In practice this usually means that we adopt conven-tionally accepted moral principles or rules perhaps with some adjustments in order to avoid inconsist-ency or arbitrariness On this view a moral theory should like a scientific theory try to match the data and the data that a moral theory must match is p rovided by our moral intuitions As in science if a plausible theory matches most but not all of the data then the anomalous data might be rejected on the grounds that it is more likely that there was an error in the procedures for gathering that particular set of data than that the theory as a whole is mis-taken But ultimately the test of a theory is its ability to explain the data The problem with applying this model of scientific justification to ethics is that the ldquodatardquo of our moral intuitions is unreliable not just at one or two specific points but as a whole Here the facts that cultural relativists draw upon are rele-vant (even if they do not establish that cultural rela-tivism is the correct response to it) Since we know that our intuitions are strongly influenced by such things as culture and religion they are ill‐suited to serve as the fixed points against which an ethical theory must be tested Even where there is cross‐cultural agreement there may be some aspects of our intuitions on which all cultures unjustifiably favor our own interests over those of others For

example simply because we are all human beings we may have a systematic bias that leads us to give an unjustifiably low moral status to nonhuman a nimals Or because in virtually all known human societies men have taken a greater leadership role than women the moral intuitions of all societies may not adequately reflect the interests of females

Some philosophers think that it is a mistake to base ethics on principles or rules Instead they focus on what it is to be a good person ndash or in the case of the problems with which this book is concerned perhaps on what it is to be a good nurse or doctor or researcher They seek to describe the virtues that a good person or a good member of the relevant profession should possess Moral education then consists of teaching these virtues and discussing how a virtuous person would act in specific situations The question is how-ever whether we can have a notion of what a virtuous person would do in a specific situation without making a prior decision about what it is right to do After all in any particular moral dilemma different virtues may be applicable and even a particular virtue will not always give unequivocal guidance For instance if a terminally ill patient repeatedly asks a nurse or doctor for assistance in dying what response best exemplifies the virtues of a healthcare professional There seems no answer to this question short of an inquiry into whether it is right or wrong to help a patient in such circumstances to die But in that case we seem bound in the end to come back to discuss-ing such issues as whether it is right to follow moral rules or principles or to do what will have the best consequences

In the late twentieth century some feminists offered new criticisms of conventional thought about ethics They argued that the approaches to ethics taken by the influential philosophers of the past ndash all of whom have been male ndash give too much emphasis to abstract principles and the role of reason and give too little attention to personal relationships and the part played by emotion One outcome of these criticisms has been the development of an ldquoethic of carerdquo which is not so much a single ethical theory as a cluster of ways of looking at ethics which put an attitude of c aring for others at the center and seek to avoid r eliance on abstract ethical principles The ethic of care has seemed especially applicable to the work of those

6 introduction

involved in direct patient care and has recently been taken up by a number of nursing theorists as offering a more suitable alternative to other ideas of ethics Not all feminists however support this development Some worry that the adoption of a ldquocarerdquo approach by nurses may reflect and even reinforce stereotypes of women as more emotional and less rational than men They also fear that it could lead to women continuing to carry a disproportionate burden of caring for others to the exclusion of adequately caring for themselves

In this discussion of ethics we have not mentioned anything about religion This may seem odd in view of the close connection that has often been made between religion and ethics but it reflects our belief that despite this historical connection ethics and reli-gion are fundamentally independent Logically ethics is prior to religion If religious believers wish to say that a deity is good or praise her or his creation or deeds they must have a notion of goodness that is independent of their conception of the deity and what she or he does Otherwise they will be saying that the deity is good and when asked what they mean by ldquogoodrdquo they will have to refer back to the deity saying perhaps that ldquogoodrdquo means ldquoin accord-ance with the wishes of the deityrdquo In that case sen-tences such as ldquoGod is goodrdquo would be a meaningless tautology ldquoGod is goodrdquo could mean no more than ldquoGod is in accordance with Godrsquos wishesrdquo As we have already seen there are ideas of what it is for something to be ldquogoodrdquo that are not rooted in any religious belief While religions typically encourage or instruct their followers to obey a particular ethical code it is obvious that others who do not follow any religion can also think and act ethically

To say that ethics is independent of religion is not to deny that theologians or other religious believers may have a role to play in bioethics Religious traditions often have long histories of dealing with ethical dilem-mas and the accumulation of wisdom and experience that they represent can give us valuable insights into particular problems But these insights should be subject to criticism in the way that any other proposals would be If in the end we accept them it is because we have judged them sound not because they are the utterances of a pope a rabbi a mullah or a holy person

Ethics is also independent of the law in the sense that the rightness or wrongness of an act cannot be

settled by its legality or illegality Whether an act is legal or illegal may often be relevant to whether it is right or wrong because it is arguably wrong to break the law other things being equal Many people have thought that this is especially so in a democracy in which everyone has a say in making the law Another reason why the fact that an act is illegal may be a rea-son against doing it is that the legality of an act may affect the consequences that are likely to flow from it If active voluntary euthanasia is illegal then doctors who practice it risk going to jail which will cause them and their families to suffer and also mean that they will no longer be able to help other patients This can be a powerful reason for not practicing voluntary euthanasia when it is against the law but if there is only a very small chance of the offense becoming known or being proved then the weight of this con-sequentialist reason against breaking the law is reduced accordingly Whether we have an ethical obligation to obey the law and if so how much weight should be given to it is itself an issue for ethical argument

Though ethics is independent of the law in the sense just specified laws are subject to evaluation from an ethical perspective Many debates in bioethics focus on questions about what practices should be allowed ndash for example should we allow research on stem cells taken from human embryos sex selection or cloning ndash and committees set up to advise on the ethical social and legal aspects of these questions often recommend legislation to prohibit the activity in question or to allow it to be practiced under some form of regulation Discussing a question at the level of law and public policy however raises somewhat different considerations than a discussion of personal ethics because the consequences of adopting a public policy generally have much wider ramifications than the consequences of a personal choice That is why some healthcare professionals feel justified in assisting a terminally ill patient to die while at the same time opposing the legalization of physician‐assisted suicide Paradoxical as this position may appear ndash and it is certainly open to criticism ndash it is not straightforwardly inconsistent

Naturally many of the essays we have selected reflect the times in which they were written Since bioethics often comments on developments in fast‐moving

Introduction 7

areas of medicine and the biological sciences the factual content of articles in bioethics can become obsolete quite rapidly In preparing this revised edition we have taken the opportunity to cover some new issues and to include some more recent writings We have for example included new mate-rial on genetic enhancement as well as on the use of embryonic human stem cells This edition of the anthology also includes new sections on ethical issues in public health and in the neurosciences Nevertheless an article that has dated in regard to its facts often makes ethical points that are still valid

or worth considering so we have not excluded older articles for this reason

Other articles are dated in a different way During the past few decades we have become more sensitive about the ways in which our language may exclude women or reflect our prejudices regarding race or sexuality We see no merit in trying to disguise past practices on such matters so we have not excluded otherwise valuable works in bioethics on these grounds If they are jar-ring to the modern reader that may be a salutary reminder of the extent to which we all are subject to the conventions and prejudices of our times

Notes

1 See Van Rensselaer Potter Bioethics Bridge to the Future (Englewood Cliffs NJ Prentice‐Hall 1971)

2 The Karamazov Brothers trans Ignat Avsey (Oxford Oxford University Press 1994) vol I part 2 bk 5 ch 4 First published in 1879

Abortion

Part I

xvi acknowledgments

68 Mark Siegler ldquoConfidentiality in Medicine A Decrepit Conceptrdquo pp 1518ndash21 from New England Journal of Medicine 307 24 (December 1982) Copyright copy 1982 Massachusetts Medical Society Reprinted with permission from Massachusetts Medical Society

69 Christian Saumlfken and Andreas Frewer ldquoThe Duty to Warn and Clinical Ethics Legal and Ethical Aspects of Confidentiality and HIVAIDSrdquo pp 313ndash326 from HEC Forum 19 4 (2007) With kind permission from Springer Science+Business Media

70 Immanuel Kant ldquoOn a Supposed Right to Lie from Altruistic Motivesrdquo pp 361ndash3 from Critique of Practical Reason and Other Works on the Theory of Ethics 6th edition trans T K Abbott London 1909 This essay was first published in a Berlin periodical in 1797

71 Joseph Collins ldquoShould Doctors Tell the Truthrdquo pp 320ndash6 from Harperrsquos Monthly Magazine 155 (August 1927) Copyright copy 1927 Harperrsquos Magazine All rights reserved Reproduced from the August issue by special permission

72 Roger Higgs ldquoOn Telling Patients the Truthrdquo pp 186ndash202 and 232ndash3 from Michael Lockwood (ed) Moral Dilemmas in Modern Medicine Oxford Oxford University Press 1985 By permission of Oxford University Press

73 John Stuart Mill ldquoOn Libertyrdquo first published in 1859

74 Justice Benjamin N Cardozo Judgment from Schloendorff v New York Hospital (1914) p 526 from Jay Katz (ed) Experimentation with Human Beings The Authority of the Investigator Subject Professions and State in the Human Experimentation Process New York Russell Sage Foundation 1972 Reproduced with permission of Russell Sage Foundation

75 Tom L Beauchamp ldquoInformed Consent Its History Meaning and Present Challengesrdquo pp 515ndash23 from Cambridge Quarterly of Health Care Ethics 20 4 (2011) copy Royal Institute of Philosophy published by Cambridge University Press Reproduced with permission from Cambridge University Press and T Beauchamp

76 Ruth Macklin ldquoThe DoctorndashPatient Relationshyship in Different Culturesrdquo pp 86ndash107 from

Against Relativism Cultural Diversity and the Search of Ethical Universals in Medicine copy 1999 by Oxford University Press Inc By permission of Oxford University Press USA

77 Carl Elliott ldquoAmputees by Choicerdquo pp 208ndash10 210ndash15 219ndash23 227ndash31 234ndash6 323ndash6 from Better Than Well American Medicine Meets the American Dream New York and London WW Norton 2003 Copyright copy 2003 by Carl Elliott Used by permission of W W Norton amp Company Inc

78 Julian Savulescu ldquoRational Desires and the Limishytation of Life‐Sustaining Treatmentrdquo pp 191ndash 222 from Bioethics 8 3 (1994) Reproduced with permission from John Wiley amp Sons

79 Shlomo Cohen ldquoThe Nocebo Effect of Informed Consentrdquo pp 147ndash54 from Bioethics 28 3 (2014) Reproduced with permission from John Wiley amp Sons

80 Sarah E Dock ldquoThe Relation of the Nurse to the Doctor and the Doctor to the Nurserdquo p 394 (extract) from The American Journal of Nursing 17 5 (1917)

81 Lisa H Newton ldquoIn Defense of the Traditional Nurserdquo pp 348ndash54 from Nursing Outlook 29 6 (1981) Copyright Elsevier 1981

82 Sarah Breier ldquoPatient Autonomy and Medical Paternity Can Nurses Help Doctors to Listen to Patientsrdquo pp 510ndash21 from Nursing Ethics 8 6 (2001) Reproduced with permission from Sage and S Breier

83 Carol Pavlish Anita Ho and Ann‐Marie Rounkle ldquoHealth and Human Rights Advocacy Perspectives from a Rwandan Refugee Camprdquo pp 538ndash49 from Nursing Ethics 19 4 (2012) Copyright copy 2012 by SAGE Publications Reprinted by Permission of SAGE

84 Jonathan D Moreno ldquoNeuroethics An Agenda for Neuroscience and Societyrdquo pp 149ndash53 from Nature Reviews 4 (February 2003)Reprinted by permission from Macmillan Publishers Ltd

85 Sally Adee ldquoHow Electrical Brain Stimulation Can Change the Way We Thinkrdquo The Week March 30 2012

86 Neil Levy ldquoNeuroethics Ethics and the Sciences of the Mindrdquo pp 69ndash74 (extract) from Philosophy

Acknowledgments xvii

Compass 4 10 (2009) pp 69ndash81 Reproduced with permission from John Wiley amp Sons

87 Adam Kolber ldquoFreedom of Memory Todayrdquo pp 145ndash8 from Neuroethics 1 (2008) With kind permission from Springer Science+Business Media

88 Henry Greely and Colleagues ldquoTowards Responsible Use of Cognitive‐Enhancing Drugs

by the Healthyrdquo pp 702ndash5 from Nature 456 (December 11 2008) Reprinted by permission from Macmillan Publishers Ltd

89 Julian Savulescu and Anders Sandberg ldquoEngineering LoverdquoldquoLove Machine Engineering Lifelong Romancerdquo pp 28ndash9 from New Scientist 2864 copy 2012 Reed Business Information ndash UK All rights reserved Distributed by Tribune Content Agency

Bioethics An Anthology Third Edition Edited by Helga Kuhse Udo Schuumlklenk and Peter Singer copy 2016 John Wiley amp Sons Inc Published 2016 by John Wiley amp Sons Inc

Introduction

The term ldquobioethicsrdquo was coined by Van Rensselaer Potter who used it to describe his proposal that we need an ethic that can incorporate our obligations not just to other humans but to the biosphere as a whole1 Although the term is still occasionally used in this sense of an ecological ethic it is now much more commonly used in the narrower sense of the study of ethical issues arising from the biological and medical sciences So understood bioethics has become a specialized although interdisciplinary area of study The essays included in this book give an indication of the range of issues which fall within its scope ndash but it is only an indication There are many other issues that we simply have not had the space to cover

Bioethics can be seen as a branch of ethics or more specifically of applied ethics For this reason some understanding of the nature of ethics is an essential preliminary to any serious study of bioethics The remainder of this introduction will seek to provide that understanding

One question about the nature of ethics is especially relevant to bioethics to what extent is reasoning or argument possible in ethics Many people assume without much thought that ethics is subjective The subjectivist holds that what ethical view we take is a matter of opinion or taste that is not amenable to argument But if ethics were a matter of taste why would we even attempt to argue about it If Helen says ldquoI like my coffee sweetenedrdquo whereas Paul says

ldquoI like my coffee unsweetenedrdquo there is not much point in Helen and Paul arguing about it The two statements do not contradict each other They can both be true But if Helen says ldquoDoctors should never assist their patients to dierdquo whereas Paul says ldquoSometimes doctors should assist their patients to dierdquo then Helen and Paul are disagreeing and there does seem to be a point in their trying to argue about the issue of physician‐assisted suicide

It seems clear that there is some scope for argument in ethics If I say ldquoIt is always wrong to kill a human beingrdquo and ldquoAbortion is not always wrongrdquo then I am committed to denying that abortion kills a human being Otherwise I have contradicted myself and in doing so I have not stated a coherent position at all So consistency at least is a requirement of any defensible ethical position and thus sets a limit to the subjectivity of ethical judgments The requirement of factual accuracy sets another limit In discussing issues in bioethics the facts are often complex But we cannot reach the right ethical decisions unless we are well‐informed about the relevant facts In this respect ethical decisions are unlike decisions of taste We can enjoy a taste without knowing what we are eating but if we assume that it is wrong to resuscitate a terminally ill patient against her wishes then we can-not know whether an instance of resuscitation was morally right or wrong without knowing something about the patientrsquos prognosis and whether the patient

2 introduction

has expressed any wishes about being resuscitated In that sense there is no equivalent in ethics to the immediacy of taste

Ethical relativism sometimes also known as cul-tural relativism is one step away from ethical sub-jectivism but it also severely limits the scope of ethical argument The ethical relativist holds that it is not individual attitudes that determine what is right or wrong but the attitudes of the culture in which one lives Herodotus tells how Darius King of Persia summoned the Greeks from the western shores of his kingdom before him and asked them how much he would have to pay them to eat their fathersrsquo dead bodies They were horrified by the idea and said they would not do it for any amount of money for it was their custom to cremate their dead Then Darius called upon Indians from the eastern frontiers of his kingdom and asked them what would make them willing to burn their fathersrsquo bodies They cried out and asked the King to refrain from mentioning so shocking an act Herodotus comments that each nation thinks its own customs best From here it is only a short step to the view that there can be no objective right or wrong beyond the bounds of onersquos own culture This view found increased support in the nine-teenth century as Western anthropologists came to know many different cultures and were impressed by ethical views very different from those that were standardly taken for granted in European society As a defense against the automatic assumption that Western morality is superior and should be imposed on ldquosavagesrdquo many anthropologists argued that since morality is relative to culture no culture can have any basis for regarding its morality as superior to any other culture

Although the motives with which anthropolo-gists put this view forward were admirable they may not have appreciated the implications of the position they were taking The ethical relativist maintains that a statement like ldquoIt is good to enslave people from another tribe if they are captured in warrdquo means simply ldquoIn my society the custom is to enslave people from another tribe if they are cap-tured in warrdquo Hence if one member of the society were to question whether it really was good to enslave people in these circumstances she could be

answered simply by demonstrating that this was indeed the custom ndash for example by showing that for many generations it had been done after every war in which prisoners were captured Thus there is no way for moral reformers to say that an accepted custom is wrong ndash ldquowrongrdquo just means ldquoin accord-ance with an accepted customrdquo

On the other hand when people from two different cultures disagree about an ethical issue then according to the ethical relativist there can be no resolution of the disagreement Indeed strictly there is no disagree-ment If the apparent dispute were over the issue just mentioned then one person would be saying ldquoIn my country it is the custom to enslave people from another tribe if they are captured in warrdquo and the other person would be saying ldquoIn my country it is not the custom to allow one human being to enslave anotherrdquo This is no more a disagreement than such statements as ldquoIn my country people greet each other by rubbing nosesrdquo and ldquoIn my country people greet each other by shaking handsrdquo If ethical relativism is true then it is impossible to say that one culture is right and the other is wrong Bearing in mind that some cultures have practiced slavery or the burning of widows on the funeral pyre of their husbands this is hard to accept

A more promising alternative to both ethical subjectivism and cultural relativism is universal pre-scriptivism an approach to ethics developed by the Oxford philosopher R M Hare Hare argues that the distinctive property of ethical judgments is that they are universalizable In saying this he means that if I make an ethical judgment I must be prepared to state it in universal terms and apply it to all relevantly similar situations By ldquouniversal termsrdquo Hare means those terms that do not refer to a particular individual Thus a proper name cannot be a universal term If for example I were to say ldquoEveryone should do what is in the interests of Mick Jaggerrdquo I would not be making a universal judgment because I have used a proper name The same would be true if I were to say that everyone must do what is in my interests because the personal pronoun ldquomyrdquo is here used to refer to a particular individual myself

It might seem that ruling out particular terms in this way does not take us very far After all one can always describe oneself in universal terms Perhaps

Introduction 3

I canrsquot say that everyone should do what is in my interests but I could say that everyone must do whatever is in the interests of people who hellip and then give a minutely detailed description of myself including the precise location of all my freckles The effect would be the same as saying that everyone should do what is in my interests because there would be no one except me who matches that description But Hare meets this problem very effectively by saying that to prescribe an ethical judgment universally means being prepared to pre-scribe it for all possible circumstances including hypothetical ones So if I were to say that everyone should do what is in the interests of a person with a particular pattern of freckles I must be prepared to prescribe that in the hypothetical situation in which I do not have this pattern of freckles but someone else does I should do what is in the interests of that person Now of course I may say that I should do that since I am confident that I shall never be in such a situation but this simply means that I am being dishonest I am not genuinely prescribing the principle universally

The effect of saying that an ethical judgment must be universalizable for hypothetical as well as actual circumstances is that whenever I make an ethical judgment I can be challenged to put myself in the position of the parties affected and see if I would still be able to accept that judgment Suppose for example that I own a small factory and the cheapest way for me to get rid of some waste is to pour it into a nearby river I do not take water from this river but I know that some villagers living downstream do and the waste may make them ill The requirement that ethical judgments should be universalizable will make it difficult for me to justify my conduct because if I imagine myself in the hypothetical situation of being one of the villagers rather than the factory‐owner I would not accept that the profits of the factory‐owner should outweigh the risk of adverse effects on my health and that of my children In this way Harersquos approach requires us to take into account the interests and preferences of all others affected by our actions Hence it allows for an element of reasoning in ethical deliberation

Since the rightness or wrongness of our actions will on this view depend on the way in which they

affect others Harersquos universal prescriptivism leads to a form of consequentialism ndash that is the view that the rightness of an action depends on its consequences The best‐known form of consequentialism is the clas-sical utilitarianism developed in the late eighteenth century by Jeremy Bentham and popularized in the nineteenth century by John Stuart Mill They held that an action is right if it leads to a greater surplus of happiness over misery than any possible alternative and wrong if it does not By ldquogreater surplus of happinessrdquo the classical utilitarians had in mind the idea of adding up all the pleasure or happiness that resulted from the action and subtracting from that total all the pain or misery to which the action gave rise Naturally in some circumstances it might be possible only to reduce misery and then the right action should be understood as the one that will result in less misery than any possible alternative

The utilitarian view is striking in many ways It puts forward a single principle that it claims can provide the right answer to all ethical dilemmas if only we can predict what the consequences of our actions will be It takes ethics out of the mysterious realm of duties and rules and bases ethical decisions on something that almost everyone understands and values Moreover utilitarianismrsquos single principle is applied universally without fear or favor Bentham said ldquoEach to count for one and none for more than onerdquo by which he meant that the happiness of a com-mon tramp counted for as much as that of a noble and the happiness of an African was no less important than that of a European

Many contemporary consequentialists agree with Bentham to the extent that they think the rightness or wrongness of an action must depend on its conse-quences but they have abandoned the idea that m aximizing net happiness is the ultimate goal Instead they argue that we should seek to bring about w hatever will satisfy the greatest number of desires or preference This variation which is known as ldquop reference utilitarianismrdquo does not regard anything as good except in so far as it is wanted or desired More intense or strongly held preferences would get more weight than weak preferences

Consequentialism offers one important answer to the question of how we should decide what is right and what is wrong but many ethicists reject it The

4 introduction

denial of this view was dramatically presented by Dostoevsky in The Karamazov Brothers

imagine that you are charged with building the edifice of human destiny the ultimate aim of which is to bring people happiness to give them peace and contentment at last but that in order to achieve this it is essential and unavoidable to torture just one little speck of creation that same little child beating her chest with her little fists and imagine that this edifice has to be erected on her unexpiated tears Would you agree to be the architect under those conditions Tell me honestly2

The passage suggests that some things are always wrong no matter what their consequences This has for most of Western history been the prevailing approach to morality at least at the level of what has been officially taught and approved by the institutions of Church and State The ten commandments of the Hebrew scriptures served as a model for much of the Christian era and the Roman Catholic Church built up an elaborate system of morality based on rules to which no exceptions were allowed

Another example of an ethic of rules is that of Immanuel Kant Kantrsquos ethic is based on his ldquocategori-cal imperativerdquo which he states in several distinct for-mulations One is that we must always act so that we can will the maxim of our action to be a universal law This can be interpreted as a form of Harersquos idea of universalizability which we have already encountered Another is that we must always treat other people as ends never as means While these formulations of the categorical imperative might be applied in various ways in Kantrsquos hands they lead to inviolable rules for example against making promises that we do not intend to keep Kant also thought that it was always wrong to tell a lie In response to a critic who sug-gested that this rule has exceptions Kant said that it would be wrong to lie even if someone had taken refuge in your house and a person seeking to murder him came to your door and asked if you knew where he was Modern Kantians often reject this hard-line approach to rules and claim that Kantrsquos categorical imperative did not require him to hold so strictly to the rule against lying

How would a consequentialist ndash for example a classical utilitarian ndash answer Dostoevskyrsquos challenge If answering honestly ndash and if one really could be certain

that this was a sure way and the only way of bringing lasting happiness to all the people of the world ndash utilitarians would have to say yes they would accept the task of being the architect of the happiness of the world at the cost of the childrsquos unexpiated tears For they would point out that the suffering of that child wholly undeserved as it is will be repeated a million‐fold over the next century for other children just as innocent who are victims of starvation disease and brutality So if this one child must be sacrificed to stop all this suffering then terrible as it is the child must be sacrificed

Fantasy apart there can be no architect of the hap-piness of the world The world is too big and complex a place for that But we may attempt to bring about less suffering and more happiness or satisfaction of preferences for people or sentient beings in specific places and circumstances Alternatively we might fol-low a set of principles or rules ndash which could be of varying degrees of rigidity or flexibility Where would such rules come from Kant tried to deduce them from his categorical imperative which in turn he had reached by insisting that the moral law must be based on reason alone without any content from our wants or desires But the problem with trying to deduce morality from reason alone has always been that it becomes an empty formalism that cannot tell us what to do To make it practical it needs to have some addi-tional content and Kantrsquos own attempts to deduce rules of conduct from his categorical imperative are unconvincing

Others following Aristotle have tried to draw on human nature as a source of moral rules What is good they say is what is natural to human beings They then contend that it is natural and right for us to seek certain goods such as knowledge friendship health love and procreation and unnatural and wrong for us to act contrary to these goods This ldquonatural lawrdquo ethic is open to criticism on several points The word ldquonaturalrdquo can be used both descriptively and evalua-tively and the two senses are often mixed together so that value judgments may be smuggled in under the guise of a description The picture of human nature presented by proponents of natural law ethics usually selects only those characteristics of our nature that the proponent considers desirable The fact that our species especially its male members frequently go to war and

Introduction 5

are also prone to commit individual acts of violence against others is no doubt just as much part of our nature as our desire for knowledge but no natural law theorist therefore views these activities as good More generally natural law theory has its origins in an Aristotelian idea of the cosmos in which everything has a goal or ldquoendrdquo which can be deduced from its nature The ldquoendrdquo of a knife is to cut the assumption is that human beings also have an ldquoendrdquo and we will flourish when we live in accordance with the end for which we are suited But this is a pre‐Darwinian view of nature Since Darwin we know that we do not exist for any purpose but are the result of natural selection operating on random mutations over millions of years Hence there is no reason to believe that living accord-ing to nature will produce a harmonious society let alone the best possible state of affairs for human beings

Another way in which it has been claimed that we can come to know what moral principles or rules we should follow is through our intuition In practice this usually means that we adopt conven-tionally accepted moral principles or rules perhaps with some adjustments in order to avoid inconsist-ency or arbitrariness On this view a moral theory should like a scientific theory try to match the data and the data that a moral theory must match is p rovided by our moral intuitions As in science if a plausible theory matches most but not all of the data then the anomalous data might be rejected on the grounds that it is more likely that there was an error in the procedures for gathering that particular set of data than that the theory as a whole is mis-taken But ultimately the test of a theory is its ability to explain the data The problem with applying this model of scientific justification to ethics is that the ldquodatardquo of our moral intuitions is unreliable not just at one or two specific points but as a whole Here the facts that cultural relativists draw upon are rele-vant (even if they do not establish that cultural rela-tivism is the correct response to it) Since we know that our intuitions are strongly influenced by such things as culture and religion they are ill‐suited to serve as the fixed points against which an ethical theory must be tested Even where there is cross‐cultural agreement there may be some aspects of our intuitions on which all cultures unjustifiably favor our own interests over those of others For

example simply because we are all human beings we may have a systematic bias that leads us to give an unjustifiably low moral status to nonhuman a nimals Or because in virtually all known human societies men have taken a greater leadership role than women the moral intuitions of all societies may not adequately reflect the interests of females

Some philosophers think that it is a mistake to base ethics on principles or rules Instead they focus on what it is to be a good person ndash or in the case of the problems with which this book is concerned perhaps on what it is to be a good nurse or doctor or researcher They seek to describe the virtues that a good person or a good member of the relevant profession should possess Moral education then consists of teaching these virtues and discussing how a virtuous person would act in specific situations The question is how-ever whether we can have a notion of what a virtuous person would do in a specific situation without making a prior decision about what it is right to do After all in any particular moral dilemma different virtues may be applicable and even a particular virtue will not always give unequivocal guidance For instance if a terminally ill patient repeatedly asks a nurse or doctor for assistance in dying what response best exemplifies the virtues of a healthcare professional There seems no answer to this question short of an inquiry into whether it is right or wrong to help a patient in such circumstances to die But in that case we seem bound in the end to come back to discuss-ing such issues as whether it is right to follow moral rules or principles or to do what will have the best consequences

In the late twentieth century some feminists offered new criticisms of conventional thought about ethics They argued that the approaches to ethics taken by the influential philosophers of the past ndash all of whom have been male ndash give too much emphasis to abstract principles and the role of reason and give too little attention to personal relationships and the part played by emotion One outcome of these criticisms has been the development of an ldquoethic of carerdquo which is not so much a single ethical theory as a cluster of ways of looking at ethics which put an attitude of c aring for others at the center and seek to avoid r eliance on abstract ethical principles The ethic of care has seemed especially applicable to the work of those

6 introduction

involved in direct patient care and has recently been taken up by a number of nursing theorists as offering a more suitable alternative to other ideas of ethics Not all feminists however support this development Some worry that the adoption of a ldquocarerdquo approach by nurses may reflect and even reinforce stereotypes of women as more emotional and less rational than men They also fear that it could lead to women continuing to carry a disproportionate burden of caring for others to the exclusion of adequately caring for themselves

In this discussion of ethics we have not mentioned anything about religion This may seem odd in view of the close connection that has often been made between religion and ethics but it reflects our belief that despite this historical connection ethics and reli-gion are fundamentally independent Logically ethics is prior to religion If religious believers wish to say that a deity is good or praise her or his creation or deeds they must have a notion of goodness that is independent of their conception of the deity and what she or he does Otherwise they will be saying that the deity is good and when asked what they mean by ldquogoodrdquo they will have to refer back to the deity saying perhaps that ldquogoodrdquo means ldquoin accord-ance with the wishes of the deityrdquo In that case sen-tences such as ldquoGod is goodrdquo would be a meaningless tautology ldquoGod is goodrdquo could mean no more than ldquoGod is in accordance with Godrsquos wishesrdquo As we have already seen there are ideas of what it is for something to be ldquogoodrdquo that are not rooted in any religious belief While religions typically encourage or instruct their followers to obey a particular ethical code it is obvious that others who do not follow any religion can also think and act ethically

To say that ethics is independent of religion is not to deny that theologians or other religious believers may have a role to play in bioethics Religious traditions often have long histories of dealing with ethical dilem-mas and the accumulation of wisdom and experience that they represent can give us valuable insights into particular problems But these insights should be subject to criticism in the way that any other proposals would be If in the end we accept them it is because we have judged them sound not because they are the utterances of a pope a rabbi a mullah or a holy person

Ethics is also independent of the law in the sense that the rightness or wrongness of an act cannot be

settled by its legality or illegality Whether an act is legal or illegal may often be relevant to whether it is right or wrong because it is arguably wrong to break the law other things being equal Many people have thought that this is especially so in a democracy in which everyone has a say in making the law Another reason why the fact that an act is illegal may be a rea-son against doing it is that the legality of an act may affect the consequences that are likely to flow from it If active voluntary euthanasia is illegal then doctors who practice it risk going to jail which will cause them and their families to suffer and also mean that they will no longer be able to help other patients This can be a powerful reason for not practicing voluntary euthanasia when it is against the law but if there is only a very small chance of the offense becoming known or being proved then the weight of this con-sequentialist reason against breaking the law is reduced accordingly Whether we have an ethical obligation to obey the law and if so how much weight should be given to it is itself an issue for ethical argument

Though ethics is independent of the law in the sense just specified laws are subject to evaluation from an ethical perspective Many debates in bioethics focus on questions about what practices should be allowed ndash for example should we allow research on stem cells taken from human embryos sex selection or cloning ndash and committees set up to advise on the ethical social and legal aspects of these questions often recommend legislation to prohibit the activity in question or to allow it to be practiced under some form of regulation Discussing a question at the level of law and public policy however raises somewhat different considerations than a discussion of personal ethics because the consequences of adopting a public policy generally have much wider ramifications than the consequences of a personal choice That is why some healthcare professionals feel justified in assisting a terminally ill patient to die while at the same time opposing the legalization of physician‐assisted suicide Paradoxical as this position may appear ndash and it is certainly open to criticism ndash it is not straightforwardly inconsistent

Naturally many of the essays we have selected reflect the times in which they were written Since bioethics often comments on developments in fast‐moving

Introduction 7

areas of medicine and the biological sciences the factual content of articles in bioethics can become obsolete quite rapidly In preparing this revised edition we have taken the opportunity to cover some new issues and to include some more recent writings We have for example included new mate-rial on genetic enhancement as well as on the use of embryonic human stem cells This edition of the anthology also includes new sections on ethical issues in public health and in the neurosciences Nevertheless an article that has dated in regard to its facts often makes ethical points that are still valid

or worth considering so we have not excluded older articles for this reason

Other articles are dated in a different way During the past few decades we have become more sensitive about the ways in which our language may exclude women or reflect our prejudices regarding race or sexuality We see no merit in trying to disguise past practices on such matters so we have not excluded otherwise valuable works in bioethics on these grounds If they are jar-ring to the modern reader that may be a salutary reminder of the extent to which we all are subject to the conventions and prejudices of our times

Notes

1 See Van Rensselaer Potter Bioethics Bridge to the Future (Englewood Cliffs NJ Prentice‐Hall 1971)

2 The Karamazov Brothers trans Ignat Avsey (Oxford Oxford University Press 1994) vol I part 2 bk 5 ch 4 First published in 1879

Abortion

Part I

Acknowledgments xvii

Compass 4 10 (2009) pp 69ndash81 Reproduced with permission from John Wiley amp Sons

87 Adam Kolber ldquoFreedom of Memory Todayrdquo pp 145ndash8 from Neuroethics 1 (2008) With kind permission from Springer Science+Business Media

88 Henry Greely and Colleagues ldquoTowards Responsible Use of Cognitive‐Enhancing Drugs

by the Healthyrdquo pp 702ndash5 from Nature 456 (December 11 2008) Reprinted by permission from Macmillan Publishers Ltd

89 Julian Savulescu and Anders Sandberg ldquoEngineering LoverdquoldquoLove Machine Engineering Lifelong Romancerdquo pp 28ndash9 from New Scientist 2864 copy 2012 Reed Business Information ndash UK All rights reserved Distributed by Tribune Content Agency

Bioethics An Anthology Third Edition Edited by Helga Kuhse Udo Schuumlklenk and Peter Singer copy 2016 John Wiley amp Sons Inc Published 2016 by John Wiley amp Sons Inc

Introduction

The term ldquobioethicsrdquo was coined by Van Rensselaer Potter who used it to describe his proposal that we need an ethic that can incorporate our obligations not just to other humans but to the biosphere as a whole1 Although the term is still occasionally used in this sense of an ecological ethic it is now much more commonly used in the narrower sense of the study of ethical issues arising from the biological and medical sciences So understood bioethics has become a specialized although interdisciplinary area of study The essays included in this book give an indication of the range of issues which fall within its scope ndash but it is only an indication There are many other issues that we simply have not had the space to cover

Bioethics can be seen as a branch of ethics or more specifically of applied ethics For this reason some understanding of the nature of ethics is an essential preliminary to any serious study of bioethics The remainder of this introduction will seek to provide that understanding

One question about the nature of ethics is especially relevant to bioethics to what extent is reasoning or argument possible in ethics Many people assume without much thought that ethics is subjective The subjectivist holds that what ethical view we take is a matter of opinion or taste that is not amenable to argument But if ethics were a matter of taste why would we even attempt to argue about it If Helen says ldquoI like my coffee sweetenedrdquo whereas Paul says

ldquoI like my coffee unsweetenedrdquo there is not much point in Helen and Paul arguing about it The two statements do not contradict each other They can both be true But if Helen says ldquoDoctors should never assist their patients to dierdquo whereas Paul says ldquoSometimes doctors should assist their patients to dierdquo then Helen and Paul are disagreeing and there does seem to be a point in their trying to argue about the issue of physician‐assisted suicide

It seems clear that there is some scope for argument in ethics If I say ldquoIt is always wrong to kill a human beingrdquo and ldquoAbortion is not always wrongrdquo then I am committed to denying that abortion kills a human being Otherwise I have contradicted myself and in doing so I have not stated a coherent position at all So consistency at least is a requirement of any defensible ethical position and thus sets a limit to the subjectivity of ethical judgments The requirement of factual accuracy sets another limit In discussing issues in bioethics the facts are often complex But we cannot reach the right ethical decisions unless we are well‐informed about the relevant facts In this respect ethical decisions are unlike decisions of taste We can enjoy a taste without knowing what we are eating but if we assume that it is wrong to resuscitate a terminally ill patient against her wishes then we can-not know whether an instance of resuscitation was morally right or wrong without knowing something about the patientrsquos prognosis and whether the patient

2 introduction

has expressed any wishes about being resuscitated In that sense there is no equivalent in ethics to the immediacy of taste

Ethical relativism sometimes also known as cul-tural relativism is one step away from ethical sub-jectivism but it also severely limits the scope of ethical argument The ethical relativist holds that it is not individual attitudes that determine what is right or wrong but the attitudes of the culture in which one lives Herodotus tells how Darius King of Persia summoned the Greeks from the western shores of his kingdom before him and asked them how much he would have to pay them to eat their fathersrsquo dead bodies They were horrified by the idea and said they would not do it for any amount of money for it was their custom to cremate their dead Then Darius called upon Indians from the eastern frontiers of his kingdom and asked them what would make them willing to burn their fathersrsquo bodies They cried out and asked the King to refrain from mentioning so shocking an act Herodotus comments that each nation thinks its own customs best From here it is only a short step to the view that there can be no objective right or wrong beyond the bounds of onersquos own culture This view found increased support in the nine-teenth century as Western anthropologists came to know many different cultures and were impressed by ethical views very different from those that were standardly taken for granted in European society As a defense against the automatic assumption that Western morality is superior and should be imposed on ldquosavagesrdquo many anthropologists argued that since morality is relative to culture no culture can have any basis for regarding its morality as superior to any other culture

Although the motives with which anthropolo-gists put this view forward were admirable they may not have appreciated the implications of the position they were taking The ethical relativist maintains that a statement like ldquoIt is good to enslave people from another tribe if they are captured in warrdquo means simply ldquoIn my society the custom is to enslave people from another tribe if they are cap-tured in warrdquo Hence if one member of the society were to question whether it really was good to enslave people in these circumstances she could be

answered simply by demonstrating that this was indeed the custom ndash for example by showing that for many generations it had been done after every war in which prisoners were captured Thus there is no way for moral reformers to say that an accepted custom is wrong ndash ldquowrongrdquo just means ldquoin accord-ance with an accepted customrdquo

On the other hand when people from two different cultures disagree about an ethical issue then according to the ethical relativist there can be no resolution of the disagreement Indeed strictly there is no disagree-ment If the apparent dispute were over the issue just mentioned then one person would be saying ldquoIn my country it is the custom to enslave people from another tribe if they are captured in warrdquo and the other person would be saying ldquoIn my country it is not the custom to allow one human being to enslave anotherrdquo This is no more a disagreement than such statements as ldquoIn my country people greet each other by rubbing nosesrdquo and ldquoIn my country people greet each other by shaking handsrdquo If ethical relativism is true then it is impossible to say that one culture is right and the other is wrong Bearing in mind that some cultures have practiced slavery or the burning of widows on the funeral pyre of their husbands this is hard to accept

A more promising alternative to both ethical subjectivism and cultural relativism is universal pre-scriptivism an approach to ethics developed by the Oxford philosopher R M Hare Hare argues that the distinctive property of ethical judgments is that they are universalizable In saying this he means that if I make an ethical judgment I must be prepared to state it in universal terms and apply it to all relevantly similar situations By ldquouniversal termsrdquo Hare means those terms that do not refer to a particular individual Thus a proper name cannot be a universal term If for example I were to say ldquoEveryone should do what is in the interests of Mick Jaggerrdquo I would not be making a universal judgment because I have used a proper name The same would be true if I were to say that everyone must do what is in my interests because the personal pronoun ldquomyrdquo is here used to refer to a particular individual myself

It might seem that ruling out particular terms in this way does not take us very far After all one can always describe oneself in universal terms Perhaps

Introduction 3

I canrsquot say that everyone should do what is in my interests but I could say that everyone must do whatever is in the interests of people who hellip and then give a minutely detailed description of myself including the precise location of all my freckles The effect would be the same as saying that everyone should do what is in my interests because there would be no one except me who matches that description But Hare meets this problem very effectively by saying that to prescribe an ethical judgment universally means being prepared to pre-scribe it for all possible circumstances including hypothetical ones So if I were to say that everyone should do what is in the interests of a person with a particular pattern of freckles I must be prepared to prescribe that in the hypothetical situation in which I do not have this pattern of freckles but someone else does I should do what is in the interests of that person Now of course I may say that I should do that since I am confident that I shall never be in such a situation but this simply means that I am being dishonest I am not genuinely prescribing the principle universally

The effect of saying that an ethical judgment must be universalizable for hypothetical as well as actual circumstances is that whenever I make an ethical judgment I can be challenged to put myself in the position of the parties affected and see if I would still be able to accept that judgment Suppose for example that I own a small factory and the cheapest way for me to get rid of some waste is to pour it into a nearby river I do not take water from this river but I know that some villagers living downstream do and the waste may make them ill The requirement that ethical judgments should be universalizable will make it difficult for me to justify my conduct because if I imagine myself in the hypothetical situation of being one of the villagers rather than the factory‐owner I would not accept that the profits of the factory‐owner should outweigh the risk of adverse effects on my health and that of my children In this way Harersquos approach requires us to take into account the interests and preferences of all others affected by our actions Hence it allows for an element of reasoning in ethical deliberation

Since the rightness or wrongness of our actions will on this view depend on the way in which they

affect others Harersquos universal prescriptivism leads to a form of consequentialism ndash that is the view that the rightness of an action depends on its consequences The best‐known form of consequentialism is the clas-sical utilitarianism developed in the late eighteenth century by Jeremy Bentham and popularized in the nineteenth century by John Stuart Mill They held that an action is right if it leads to a greater surplus of happiness over misery than any possible alternative and wrong if it does not By ldquogreater surplus of happinessrdquo the classical utilitarians had in mind the idea of adding up all the pleasure or happiness that resulted from the action and subtracting from that total all the pain or misery to which the action gave rise Naturally in some circumstances it might be possible only to reduce misery and then the right action should be understood as the one that will result in less misery than any possible alternative

The utilitarian view is striking in many ways It puts forward a single principle that it claims can provide the right answer to all ethical dilemmas if only we can predict what the consequences of our actions will be It takes ethics out of the mysterious realm of duties and rules and bases ethical decisions on something that almost everyone understands and values Moreover utilitarianismrsquos single principle is applied universally without fear or favor Bentham said ldquoEach to count for one and none for more than onerdquo by which he meant that the happiness of a com-mon tramp counted for as much as that of a noble and the happiness of an African was no less important than that of a European

Many contemporary consequentialists agree with Bentham to the extent that they think the rightness or wrongness of an action must depend on its conse-quences but they have abandoned the idea that m aximizing net happiness is the ultimate goal Instead they argue that we should seek to bring about w hatever will satisfy the greatest number of desires or preference This variation which is known as ldquop reference utilitarianismrdquo does not regard anything as good except in so far as it is wanted or desired More intense or strongly held preferences would get more weight than weak preferences

Consequentialism offers one important answer to the question of how we should decide what is right and what is wrong but many ethicists reject it The

4 introduction

denial of this view was dramatically presented by Dostoevsky in The Karamazov Brothers

imagine that you are charged with building the edifice of human destiny the ultimate aim of which is to bring people happiness to give them peace and contentment at last but that in order to achieve this it is essential and unavoidable to torture just one little speck of creation that same little child beating her chest with her little fists and imagine that this edifice has to be erected on her unexpiated tears Would you agree to be the architect under those conditions Tell me honestly2

The passage suggests that some things are always wrong no matter what their consequences This has for most of Western history been the prevailing approach to morality at least at the level of what has been officially taught and approved by the institutions of Church and State The ten commandments of the Hebrew scriptures served as a model for much of the Christian era and the Roman Catholic Church built up an elaborate system of morality based on rules to which no exceptions were allowed

Another example of an ethic of rules is that of Immanuel Kant Kantrsquos ethic is based on his ldquocategori-cal imperativerdquo which he states in several distinct for-mulations One is that we must always act so that we can will the maxim of our action to be a universal law This can be interpreted as a form of Harersquos idea of universalizability which we have already encountered Another is that we must always treat other people as ends never as means While these formulations of the categorical imperative might be applied in various ways in Kantrsquos hands they lead to inviolable rules for example against making promises that we do not intend to keep Kant also thought that it was always wrong to tell a lie In response to a critic who sug-gested that this rule has exceptions Kant said that it would be wrong to lie even if someone had taken refuge in your house and a person seeking to murder him came to your door and asked if you knew where he was Modern Kantians often reject this hard-line approach to rules and claim that Kantrsquos categorical imperative did not require him to hold so strictly to the rule against lying

How would a consequentialist ndash for example a classical utilitarian ndash answer Dostoevskyrsquos challenge If answering honestly ndash and if one really could be certain

that this was a sure way and the only way of bringing lasting happiness to all the people of the world ndash utilitarians would have to say yes they would accept the task of being the architect of the happiness of the world at the cost of the childrsquos unexpiated tears For they would point out that the suffering of that child wholly undeserved as it is will be repeated a million‐fold over the next century for other children just as innocent who are victims of starvation disease and brutality So if this one child must be sacrificed to stop all this suffering then terrible as it is the child must be sacrificed

Fantasy apart there can be no architect of the hap-piness of the world The world is too big and complex a place for that But we may attempt to bring about less suffering and more happiness or satisfaction of preferences for people or sentient beings in specific places and circumstances Alternatively we might fol-low a set of principles or rules ndash which could be of varying degrees of rigidity or flexibility Where would such rules come from Kant tried to deduce them from his categorical imperative which in turn he had reached by insisting that the moral law must be based on reason alone without any content from our wants or desires But the problem with trying to deduce morality from reason alone has always been that it becomes an empty formalism that cannot tell us what to do To make it practical it needs to have some addi-tional content and Kantrsquos own attempts to deduce rules of conduct from his categorical imperative are unconvincing

Others following Aristotle have tried to draw on human nature as a source of moral rules What is good they say is what is natural to human beings They then contend that it is natural and right for us to seek certain goods such as knowledge friendship health love and procreation and unnatural and wrong for us to act contrary to these goods This ldquonatural lawrdquo ethic is open to criticism on several points The word ldquonaturalrdquo can be used both descriptively and evalua-tively and the two senses are often mixed together so that value judgments may be smuggled in under the guise of a description The picture of human nature presented by proponents of natural law ethics usually selects only those characteristics of our nature that the proponent considers desirable The fact that our species especially its male members frequently go to war and

Introduction 5

are also prone to commit individual acts of violence against others is no doubt just as much part of our nature as our desire for knowledge but no natural law theorist therefore views these activities as good More generally natural law theory has its origins in an Aristotelian idea of the cosmos in which everything has a goal or ldquoendrdquo which can be deduced from its nature The ldquoendrdquo of a knife is to cut the assumption is that human beings also have an ldquoendrdquo and we will flourish when we live in accordance with the end for which we are suited But this is a pre‐Darwinian view of nature Since Darwin we know that we do not exist for any purpose but are the result of natural selection operating on random mutations over millions of years Hence there is no reason to believe that living accord-ing to nature will produce a harmonious society let alone the best possible state of affairs for human beings

Another way in which it has been claimed that we can come to know what moral principles or rules we should follow is through our intuition In practice this usually means that we adopt conven-tionally accepted moral principles or rules perhaps with some adjustments in order to avoid inconsist-ency or arbitrariness On this view a moral theory should like a scientific theory try to match the data and the data that a moral theory must match is p rovided by our moral intuitions As in science if a plausible theory matches most but not all of the data then the anomalous data might be rejected on the grounds that it is more likely that there was an error in the procedures for gathering that particular set of data than that the theory as a whole is mis-taken But ultimately the test of a theory is its ability to explain the data The problem with applying this model of scientific justification to ethics is that the ldquodatardquo of our moral intuitions is unreliable not just at one or two specific points but as a whole Here the facts that cultural relativists draw upon are rele-vant (even if they do not establish that cultural rela-tivism is the correct response to it) Since we know that our intuitions are strongly influenced by such things as culture and religion they are ill‐suited to serve as the fixed points against which an ethical theory must be tested Even where there is cross‐cultural agreement there may be some aspects of our intuitions on which all cultures unjustifiably favor our own interests over those of others For

example simply because we are all human beings we may have a systematic bias that leads us to give an unjustifiably low moral status to nonhuman a nimals Or because in virtually all known human societies men have taken a greater leadership role than women the moral intuitions of all societies may not adequately reflect the interests of females

Some philosophers think that it is a mistake to base ethics on principles or rules Instead they focus on what it is to be a good person ndash or in the case of the problems with which this book is concerned perhaps on what it is to be a good nurse or doctor or researcher They seek to describe the virtues that a good person or a good member of the relevant profession should possess Moral education then consists of teaching these virtues and discussing how a virtuous person would act in specific situations The question is how-ever whether we can have a notion of what a virtuous person would do in a specific situation without making a prior decision about what it is right to do After all in any particular moral dilemma different virtues may be applicable and even a particular virtue will not always give unequivocal guidance For instance if a terminally ill patient repeatedly asks a nurse or doctor for assistance in dying what response best exemplifies the virtues of a healthcare professional There seems no answer to this question short of an inquiry into whether it is right or wrong to help a patient in such circumstances to die But in that case we seem bound in the end to come back to discuss-ing such issues as whether it is right to follow moral rules or principles or to do what will have the best consequences

In the late twentieth century some feminists offered new criticisms of conventional thought about ethics They argued that the approaches to ethics taken by the influential philosophers of the past ndash all of whom have been male ndash give too much emphasis to abstract principles and the role of reason and give too little attention to personal relationships and the part played by emotion One outcome of these criticisms has been the development of an ldquoethic of carerdquo which is not so much a single ethical theory as a cluster of ways of looking at ethics which put an attitude of c aring for others at the center and seek to avoid r eliance on abstract ethical principles The ethic of care has seemed especially applicable to the work of those

6 introduction

involved in direct patient care and has recently been taken up by a number of nursing theorists as offering a more suitable alternative to other ideas of ethics Not all feminists however support this development Some worry that the adoption of a ldquocarerdquo approach by nurses may reflect and even reinforce stereotypes of women as more emotional and less rational than men They also fear that it could lead to women continuing to carry a disproportionate burden of caring for others to the exclusion of adequately caring for themselves

In this discussion of ethics we have not mentioned anything about religion This may seem odd in view of the close connection that has often been made between religion and ethics but it reflects our belief that despite this historical connection ethics and reli-gion are fundamentally independent Logically ethics is prior to religion If religious believers wish to say that a deity is good or praise her or his creation or deeds they must have a notion of goodness that is independent of their conception of the deity and what she or he does Otherwise they will be saying that the deity is good and when asked what they mean by ldquogoodrdquo they will have to refer back to the deity saying perhaps that ldquogoodrdquo means ldquoin accord-ance with the wishes of the deityrdquo In that case sen-tences such as ldquoGod is goodrdquo would be a meaningless tautology ldquoGod is goodrdquo could mean no more than ldquoGod is in accordance with Godrsquos wishesrdquo As we have already seen there are ideas of what it is for something to be ldquogoodrdquo that are not rooted in any religious belief While religions typically encourage or instruct their followers to obey a particular ethical code it is obvious that others who do not follow any religion can also think and act ethically

To say that ethics is independent of religion is not to deny that theologians or other religious believers may have a role to play in bioethics Religious traditions often have long histories of dealing with ethical dilem-mas and the accumulation of wisdom and experience that they represent can give us valuable insights into particular problems But these insights should be subject to criticism in the way that any other proposals would be If in the end we accept them it is because we have judged them sound not because they are the utterances of a pope a rabbi a mullah or a holy person

Ethics is also independent of the law in the sense that the rightness or wrongness of an act cannot be

settled by its legality or illegality Whether an act is legal or illegal may often be relevant to whether it is right or wrong because it is arguably wrong to break the law other things being equal Many people have thought that this is especially so in a democracy in which everyone has a say in making the law Another reason why the fact that an act is illegal may be a rea-son against doing it is that the legality of an act may affect the consequences that are likely to flow from it If active voluntary euthanasia is illegal then doctors who practice it risk going to jail which will cause them and their families to suffer and also mean that they will no longer be able to help other patients This can be a powerful reason for not practicing voluntary euthanasia when it is against the law but if there is only a very small chance of the offense becoming known or being proved then the weight of this con-sequentialist reason against breaking the law is reduced accordingly Whether we have an ethical obligation to obey the law and if so how much weight should be given to it is itself an issue for ethical argument

Though ethics is independent of the law in the sense just specified laws are subject to evaluation from an ethical perspective Many debates in bioethics focus on questions about what practices should be allowed ndash for example should we allow research on stem cells taken from human embryos sex selection or cloning ndash and committees set up to advise on the ethical social and legal aspects of these questions often recommend legislation to prohibit the activity in question or to allow it to be practiced under some form of regulation Discussing a question at the level of law and public policy however raises somewhat different considerations than a discussion of personal ethics because the consequences of adopting a public policy generally have much wider ramifications than the consequences of a personal choice That is why some healthcare professionals feel justified in assisting a terminally ill patient to die while at the same time opposing the legalization of physician‐assisted suicide Paradoxical as this position may appear ndash and it is certainly open to criticism ndash it is not straightforwardly inconsistent

Naturally many of the essays we have selected reflect the times in which they were written Since bioethics often comments on developments in fast‐moving

Introduction 7

areas of medicine and the biological sciences the factual content of articles in bioethics can become obsolete quite rapidly In preparing this revised edition we have taken the opportunity to cover some new issues and to include some more recent writings We have for example included new mate-rial on genetic enhancement as well as on the use of embryonic human stem cells This edition of the anthology also includes new sections on ethical issues in public health and in the neurosciences Nevertheless an article that has dated in regard to its facts often makes ethical points that are still valid

or worth considering so we have not excluded older articles for this reason

Other articles are dated in a different way During the past few decades we have become more sensitive about the ways in which our language may exclude women or reflect our prejudices regarding race or sexuality We see no merit in trying to disguise past practices on such matters so we have not excluded otherwise valuable works in bioethics on these grounds If they are jar-ring to the modern reader that may be a salutary reminder of the extent to which we all are subject to the conventions and prejudices of our times

Notes

1 See Van Rensselaer Potter Bioethics Bridge to the Future (Englewood Cliffs NJ Prentice‐Hall 1971)

2 The Karamazov Brothers trans Ignat Avsey (Oxford Oxford University Press 1994) vol I part 2 bk 5 ch 4 First published in 1879

Abortion

Part I

Bioethics An Anthology Third Edition Edited by Helga Kuhse Udo Schuumlklenk and Peter Singer copy 2016 John Wiley amp Sons Inc Published 2016 by John Wiley amp Sons Inc

Introduction

The term ldquobioethicsrdquo was coined by Van Rensselaer Potter who used it to describe his proposal that we need an ethic that can incorporate our obligations not just to other humans but to the biosphere as a whole1 Although the term is still occasionally used in this sense of an ecological ethic it is now much more commonly used in the narrower sense of the study of ethical issues arising from the biological and medical sciences So understood bioethics has become a specialized although interdisciplinary area of study The essays included in this book give an indication of the range of issues which fall within its scope ndash but it is only an indication There are many other issues that we simply have not had the space to cover

Bioethics can be seen as a branch of ethics or more specifically of applied ethics For this reason some understanding of the nature of ethics is an essential preliminary to any serious study of bioethics The remainder of this introduction will seek to provide that understanding

One question about the nature of ethics is especially relevant to bioethics to what extent is reasoning or argument possible in ethics Many people assume without much thought that ethics is subjective The subjectivist holds that what ethical view we take is a matter of opinion or taste that is not amenable to argument But if ethics were a matter of taste why would we even attempt to argue about it If Helen says ldquoI like my coffee sweetenedrdquo whereas Paul says

ldquoI like my coffee unsweetenedrdquo there is not much point in Helen and Paul arguing about it The two statements do not contradict each other They can both be true But if Helen says ldquoDoctors should never assist their patients to dierdquo whereas Paul says ldquoSometimes doctors should assist their patients to dierdquo then Helen and Paul are disagreeing and there does seem to be a point in their trying to argue about the issue of physician‐assisted suicide

It seems clear that there is some scope for argument in ethics If I say ldquoIt is always wrong to kill a human beingrdquo and ldquoAbortion is not always wrongrdquo then I am committed to denying that abortion kills a human being Otherwise I have contradicted myself and in doing so I have not stated a coherent position at all So consistency at least is a requirement of any defensible ethical position and thus sets a limit to the subjectivity of ethical judgments The requirement of factual accuracy sets another limit In discussing issues in bioethics the facts are often complex But we cannot reach the right ethical decisions unless we are well‐informed about the relevant facts In this respect ethical decisions are unlike decisions of taste We can enjoy a taste without knowing what we are eating but if we assume that it is wrong to resuscitate a terminally ill patient against her wishes then we can-not know whether an instance of resuscitation was morally right or wrong without knowing something about the patientrsquos prognosis and whether the patient

2 introduction

has expressed any wishes about being resuscitated In that sense there is no equivalent in ethics to the immediacy of taste

Ethical relativism sometimes also known as cul-tural relativism is one step away from ethical sub-jectivism but it also severely limits the scope of ethical argument The ethical relativist holds that it is not individual attitudes that determine what is right or wrong but the attitudes of the culture in which one lives Herodotus tells how Darius King of Persia summoned the Greeks from the western shores of his kingdom before him and asked them how much he would have to pay them to eat their fathersrsquo dead bodies They were horrified by the idea and said they would not do it for any amount of money for it was their custom to cremate their dead Then Darius called upon Indians from the eastern frontiers of his kingdom and asked them what would make them willing to burn their fathersrsquo bodies They cried out and asked the King to refrain from mentioning so shocking an act Herodotus comments that each nation thinks its own customs best From here it is only a short step to the view that there can be no objective right or wrong beyond the bounds of onersquos own culture This view found increased support in the nine-teenth century as Western anthropologists came to know many different cultures and were impressed by ethical views very different from those that were standardly taken for granted in European society As a defense against the automatic assumption that Western morality is superior and should be imposed on ldquosavagesrdquo many anthropologists argued that since morality is relative to culture no culture can have any basis for regarding its morality as superior to any other culture

Although the motives with which anthropolo-gists put this view forward were admirable they may not have appreciated the implications of the position they were taking The ethical relativist maintains that a statement like ldquoIt is good to enslave people from another tribe if they are captured in warrdquo means simply ldquoIn my society the custom is to enslave people from another tribe if they are cap-tured in warrdquo Hence if one member of the society were to question whether it really was good to enslave people in these circumstances she could be

answered simply by demonstrating that this was indeed the custom ndash for example by showing that for many generations it had been done after every war in which prisoners were captured Thus there is no way for moral reformers to say that an accepted custom is wrong ndash ldquowrongrdquo just means ldquoin accord-ance with an accepted customrdquo

On the other hand when people from two different cultures disagree about an ethical issue then according to the ethical relativist there can be no resolution of the disagreement Indeed strictly there is no disagree-ment If the apparent dispute were over the issue just mentioned then one person would be saying ldquoIn my country it is the custom to enslave people from another tribe if they are captured in warrdquo and the other person would be saying ldquoIn my country it is not the custom to allow one human being to enslave anotherrdquo This is no more a disagreement than such statements as ldquoIn my country people greet each other by rubbing nosesrdquo and ldquoIn my country people greet each other by shaking handsrdquo If ethical relativism is true then it is impossible to say that one culture is right and the other is wrong Bearing in mind that some cultures have practiced slavery or the burning of widows on the funeral pyre of their husbands this is hard to accept

A more promising alternative to both ethical subjectivism and cultural relativism is universal pre-scriptivism an approach to ethics developed by the Oxford philosopher R M Hare Hare argues that the distinctive property of ethical judgments is that they are universalizable In saying this he means that if I make an ethical judgment I must be prepared to state it in universal terms and apply it to all relevantly similar situations By ldquouniversal termsrdquo Hare means those terms that do not refer to a particular individual Thus a proper name cannot be a universal term If for example I were to say ldquoEveryone should do what is in the interests of Mick Jaggerrdquo I would not be making a universal judgment because I have used a proper name The same would be true if I were to say that everyone must do what is in my interests because the personal pronoun ldquomyrdquo is here used to refer to a particular individual myself

It might seem that ruling out particular terms in this way does not take us very far After all one can always describe oneself in universal terms Perhaps

Introduction 3

I canrsquot say that everyone should do what is in my interests but I could say that everyone must do whatever is in the interests of people who hellip and then give a minutely detailed description of myself including the precise location of all my freckles The effect would be the same as saying that everyone should do what is in my interests because there would be no one except me who matches that description But Hare meets this problem very effectively by saying that to prescribe an ethical judgment universally means being prepared to pre-scribe it for all possible circumstances including hypothetical ones So if I were to say that everyone should do what is in the interests of a person with a particular pattern of freckles I must be prepared to prescribe that in the hypothetical situation in which I do not have this pattern of freckles but someone else does I should do what is in the interests of that person Now of course I may say that I should do that since I am confident that I shall never be in such a situation but this simply means that I am being dishonest I am not genuinely prescribing the principle universally

The effect of saying that an ethical judgment must be universalizable for hypothetical as well as actual circumstances is that whenever I make an ethical judgment I can be challenged to put myself in the position of the parties affected and see if I would still be able to accept that judgment Suppose for example that I own a small factory and the cheapest way for me to get rid of some waste is to pour it into a nearby river I do not take water from this river but I know that some villagers living downstream do and the waste may make them ill The requirement that ethical judgments should be universalizable will make it difficult for me to justify my conduct because if I imagine myself in the hypothetical situation of being one of the villagers rather than the factory‐owner I would not accept that the profits of the factory‐owner should outweigh the risk of adverse effects on my health and that of my children In this way Harersquos approach requires us to take into account the interests and preferences of all others affected by our actions Hence it allows for an element of reasoning in ethical deliberation

Since the rightness or wrongness of our actions will on this view depend on the way in which they

affect others Harersquos universal prescriptivism leads to a form of consequentialism ndash that is the view that the rightness of an action depends on its consequences The best‐known form of consequentialism is the clas-sical utilitarianism developed in the late eighteenth century by Jeremy Bentham and popularized in the nineteenth century by John Stuart Mill They held that an action is right if it leads to a greater surplus of happiness over misery than any possible alternative and wrong if it does not By ldquogreater surplus of happinessrdquo the classical utilitarians had in mind the idea of adding up all the pleasure or happiness that resulted from the action and subtracting from that total all the pain or misery to which the action gave rise Naturally in some circumstances it might be possible only to reduce misery and then the right action should be understood as the one that will result in less misery than any possible alternative

The utilitarian view is striking in many ways It puts forward a single principle that it claims can provide the right answer to all ethical dilemmas if only we can predict what the consequences of our actions will be It takes ethics out of the mysterious realm of duties and rules and bases ethical decisions on something that almost everyone understands and values Moreover utilitarianismrsquos single principle is applied universally without fear or favor Bentham said ldquoEach to count for one and none for more than onerdquo by which he meant that the happiness of a com-mon tramp counted for as much as that of a noble and the happiness of an African was no less important than that of a European

Many contemporary consequentialists agree with Bentham to the extent that they think the rightness or wrongness of an action must depend on its conse-quences but they have abandoned the idea that m aximizing net happiness is the ultimate goal Instead they argue that we should seek to bring about w hatever will satisfy the greatest number of desires or preference This variation which is known as ldquop reference utilitarianismrdquo does not regard anything as good except in so far as it is wanted or desired More intense or strongly held preferences would get more weight than weak preferences

Consequentialism offers one important answer to the question of how we should decide what is right and what is wrong but many ethicists reject it The

4 introduction

denial of this view was dramatically presented by Dostoevsky in The Karamazov Brothers

imagine that you are charged with building the edifice of human destiny the ultimate aim of which is to bring people happiness to give them peace and contentment at last but that in order to achieve this it is essential and unavoidable to torture just one little speck of creation that same little child beating her chest with her little fists and imagine that this edifice has to be erected on her unexpiated tears Would you agree to be the architect under those conditions Tell me honestly2

The passage suggests that some things are always wrong no matter what their consequences This has for most of Western history been the prevailing approach to morality at least at the level of what has been officially taught and approved by the institutions of Church and State The ten commandments of the Hebrew scriptures served as a model for much of the Christian era and the Roman Catholic Church built up an elaborate system of morality based on rules to which no exceptions were allowed

Another example of an ethic of rules is that of Immanuel Kant Kantrsquos ethic is based on his ldquocategori-cal imperativerdquo which he states in several distinct for-mulations One is that we must always act so that we can will the maxim of our action to be a universal law This can be interpreted as a form of Harersquos idea of universalizability which we have already encountered Another is that we must always treat other people as ends never as means While these formulations of the categorical imperative might be applied in various ways in Kantrsquos hands they lead to inviolable rules for example against making promises that we do not intend to keep Kant also thought that it was always wrong to tell a lie In response to a critic who sug-gested that this rule has exceptions Kant said that it would be wrong to lie even if someone had taken refuge in your house and a person seeking to murder him came to your door and asked if you knew where he was Modern Kantians often reject this hard-line approach to rules and claim that Kantrsquos categorical imperative did not require him to hold so strictly to the rule against lying

How would a consequentialist ndash for example a classical utilitarian ndash answer Dostoevskyrsquos challenge If answering honestly ndash and if one really could be certain

that this was a sure way and the only way of bringing lasting happiness to all the people of the world ndash utilitarians would have to say yes they would accept the task of being the architect of the happiness of the world at the cost of the childrsquos unexpiated tears For they would point out that the suffering of that child wholly undeserved as it is will be repeated a million‐fold over the next century for other children just as innocent who are victims of starvation disease and brutality So if this one child must be sacrificed to stop all this suffering then terrible as it is the child must be sacrificed

Fantasy apart there can be no architect of the hap-piness of the world The world is too big and complex a place for that But we may attempt to bring about less suffering and more happiness or satisfaction of preferences for people or sentient beings in specific places and circumstances Alternatively we might fol-low a set of principles or rules ndash which could be of varying degrees of rigidity or flexibility Where would such rules come from Kant tried to deduce them from his categorical imperative which in turn he had reached by insisting that the moral law must be based on reason alone without any content from our wants or desires But the problem with trying to deduce morality from reason alone has always been that it becomes an empty formalism that cannot tell us what to do To make it practical it needs to have some addi-tional content and Kantrsquos own attempts to deduce rules of conduct from his categorical imperative are unconvincing

Others following Aristotle have tried to draw on human nature as a source of moral rules What is good they say is what is natural to human beings They then contend that it is natural and right for us to seek certain goods such as knowledge friendship health love and procreation and unnatural and wrong for us to act contrary to these goods This ldquonatural lawrdquo ethic is open to criticism on several points The word ldquonaturalrdquo can be used both descriptively and evalua-tively and the two senses are often mixed together so that value judgments may be smuggled in under the guise of a description The picture of human nature presented by proponents of natural law ethics usually selects only those characteristics of our nature that the proponent considers desirable The fact that our species especially its male members frequently go to war and

Introduction 5

are also prone to commit individual acts of violence against others is no doubt just as much part of our nature as our desire for knowledge but no natural law theorist therefore views these activities as good More generally natural law theory has its origins in an Aristotelian idea of the cosmos in which everything has a goal or ldquoendrdquo which can be deduced from its nature The ldquoendrdquo of a knife is to cut the assumption is that human beings also have an ldquoendrdquo and we will flourish when we live in accordance with the end for which we are suited But this is a pre‐Darwinian view of nature Since Darwin we know that we do not exist for any purpose but are the result of natural selection operating on random mutations over millions of years Hence there is no reason to believe that living accord-ing to nature will produce a harmonious society let alone the best possible state of affairs for human beings

Another way in which it has been claimed that we can come to know what moral principles or rules we should follow is through our intuition In practice this usually means that we adopt conven-tionally accepted moral principles or rules perhaps with some adjustments in order to avoid inconsist-ency or arbitrariness On this view a moral theory should like a scientific theory try to match the data and the data that a moral theory must match is p rovided by our moral intuitions As in science if a plausible theory matches most but not all of the data then the anomalous data might be rejected on the grounds that it is more likely that there was an error in the procedures for gathering that particular set of data than that the theory as a whole is mis-taken But ultimately the test of a theory is its ability to explain the data The problem with applying this model of scientific justification to ethics is that the ldquodatardquo of our moral intuitions is unreliable not just at one or two specific points but as a whole Here the facts that cultural relativists draw upon are rele-vant (even if they do not establish that cultural rela-tivism is the correct response to it) Since we know that our intuitions are strongly influenced by such things as culture and religion they are ill‐suited to serve as the fixed points against which an ethical theory must be tested Even where there is cross‐cultural agreement there may be some aspects of our intuitions on which all cultures unjustifiably favor our own interests over those of others For

example simply because we are all human beings we may have a systematic bias that leads us to give an unjustifiably low moral status to nonhuman a nimals Or because in virtually all known human societies men have taken a greater leadership role than women the moral intuitions of all societies may not adequately reflect the interests of females

Some philosophers think that it is a mistake to base ethics on principles or rules Instead they focus on what it is to be a good person ndash or in the case of the problems with which this book is concerned perhaps on what it is to be a good nurse or doctor or researcher They seek to describe the virtues that a good person or a good member of the relevant profession should possess Moral education then consists of teaching these virtues and discussing how a virtuous person would act in specific situations The question is how-ever whether we can have a notion of what a virtuous person would do in a specific situation without making a prior decision about what it is right to do After all in any particular moral dilemma different virtues may be applicable and even a particular virtue will not always give unequivocal guidance For instance if a terminally ill patient repeatedly asks a nurse or doctor for assistance in dying what response best exemplifies the virtues of a healthcare professional There seems no answer to this question short of an inquiry into whether it is right or wrong to help a patient in such circumstances to die But in that case we seem bound in the end to come back to discuss-ing such issues as whether it is right to follow moral rules or principles or to do what will have the best consequences

In the late twentieth century some feminists offered new criticisms of conventional thought about ethics They argued that the approaches to ethics taken by the influential philosophers of the past ndash all of whom have been male ndash give too much emphasis to abstract principles and the role of reason and give too little attention to personal relationships and the part played by emotion One outcome of these criticisms has been the development of an ldquoethic of carerdquo which is not so much a single ethical theory as a cluster of ways of looking at ethics which put an attitude of c aring for others at the center and seek to avoid r eliance on abstract ethical principles The ethic of care has seemed especially applicable to the work of those

6 introduction

involved in direct patient care and has recently been taken up by a number of nursing theorists as offering a more suitable alternative to other ideas of ethics Not all feminists however support this development Some worry that the adoption of a ldquocarerdquo approach by nurses may reflect and even reinforce stereotypes of women as more emotional and less rational than men They also fear that it could lead to women continuing to carry a disproportionate burden of caring for others to the exclusion of adequately caring for themselves

In this discussion of ethics we have not mentioned anything about religion This may seem odd in view of the close connection that has often been made between religion and ethics but it reflects our belief that despite this historical connection ethics and reli-gion are fundamentally independent Logically ethics is prior to religion If religious believers wish to say that a deity is good or praise her or his creation or deeds they must have a notion of goodness that is independent of their conception of the deity and what she or he does Otherwise they will be saying that the deity is good and when asked what they mean by ldquogoodrdquo they will have to refer back to the deity saying perhaps that ldquogoodrdquo means ldquoin accord-ance with the wishes of the deityrdquo In that case sen-tences such as ldquoGod is goodrdquo would be a meaningless tautology ldquoGod is goodrdquo could mean no more than ldquoGod is in accordance with Godrsquos wishesrdquo As we have already seen there are ideas of what it is for something to be ldquogoodrdquo that are not rooted in any religious belief While religions typically encourage or instruct their followers to obey a particular ethical code it is obvious that others who do not follow any religion can also think and act ethically

To say that ethics is independent of religion is not to deny that theologians or other religious believers may have a role to play in bioethics Religious traditions often have long histories of dealing with ethical dilem-mas and the accumulation of wisdom and experience that they represent can give us valuable insights into particular problems But these insights should be subject to criticism in the way that any other proposals would be If in the end we accept them it is because we have judged them sound not because they are the utterances of a pope a rabbi a mullah or a holy person

Ethics is also independent of the law in the sense that the rightness or wrongness of an act cannot be

settled by its legality or illegality Whether an act is legal or illegal may often be relevant to whether it is right or wrong because it is arguably wrong to break the law other things being equal Many people have thought that this is especially so in a democracy in which everyone has a say in making the law Another reason why the fact that an act is illegal may be a rea-son against doing it is that the legality of an act may affect the consequences that are likely to flow from it If active voluntary euthanasia is illegal then doctors who practice it risk going to jail which will cause them and their families to suffer and also mean that they will no longer be able to help other patients This can be a powerful reason for not practicing voluntary euthanasia when it is against the law but if there is only a very small chance of the offense becoming known or being proved then the weight of this con-sequentialist reason against breaking the law is reduced accordingly Whether we have an ethical obligation to obey the law and if so how much weight should be given to it is itself an issue for ethical argument

Though ethics is independent of the law in the sense just specified laws are subject to evaluation from an ethical perspective Many debates in bioethics focus on questions about what practices should be allowed ndash for example should we allow research on stem cells taken from human embryos sex selection or cloning ndash and committees set up to advise on the ethical social and legal aspects of these questions often recommend legislation to prohibit the activity in question or to allow it to be practiced under some form of regulation Discussing a question at the level of law and public policy however raises somewhat different considerations than a discussion of personal ethics because the consequences of adopting a public policy generally have much wider ramifications than the consequences of a personal choice That is why some healthcare professionals feel justified in assisting a terminally ill patient to die while at the same time opposing the legalization of physician‐assisted suicide Paradoxical as this position may appear ndash and it is certainly open to criticism ndash it is not straightforwardly inconsistent

Naturally many of the essays we have selected reflect the times in which they were written Since bioethics often comments on developments in fast‐moving

Introduction 7

areas of medicine and the biological sciences the factual content of articles in bioethics can become obsolete quite rapidly In preparing this revised edition we have taken the opportunity to cover some new issues and to include some more recent writings We have for example included new mate-rial on genetic enhancement as well as on the use of embryonic human stem cells This edition of the anthology also includes new sections on ethical issues in public health and in the neurosciences Nevertheless an article that has dated in regard to its facts often makes ethical points that are still valid

or worth considering so we have not excluded older articles for this reason

Other articles are dated in a different way During the past few decades we have become more sensitive about the ways in which our language may exclude women or reflect our prejudices regarding race or sexuality We see no merit in trying to disguise past practices on such matters so we have not excluded otherwise valuable works in bioethics on these grounds If they are jar-ring to the modern reader that may be a salutary reminder of the extent to which we all are subject to the conventions and prejudices of our times

Notes

1 See Van Rensselaer Potter Bioethics Bridge to the Future (Englewood Cliffs NJ Prentice‐Hall 1971)

2 The Karamazov Brothers trans Ignat Avsey (Oxford Oxford University Press 1994) vol I part 2 bk 5 ch 4 First published in 1879

Abortion

Part I

2 introduction

has expressed any wishes about being resuscitated In that sense there is no equivalent in ethics to the immediacy of taste

Ethical relativism sometimes also known as cul-tural relativism is one step away from ethical sub-jectivism but it also severely limits the scope of ethical argument The ethical relativist holds that it is not individual attitudes that determine what is right or wrong but the attitudes of the culture in which one lives Herodotus tells how Darius King of Persia summoned the Greeks from the western shores of his kingdom before him and asked them how much he would have to pay them to eat their fathersrsquo dead bodies They were horrified by the idea and said they would not do it for any amount of money for it was their custom to cremate their dead Then Darius called upon Indians from the eastern frontiers of his kingdom and asked them what would make them willing to burn their fathersrsquo bodies They cried out and asked the King to refrain from mentioning so shocking an act Herodotus comments that each nation thinks its own customs best From here it is only a short step to the view that there can be no objective right or wrong beyond the bounds of onersquos own culture This view found increased support in the nine-teenth century as Western anthropologists came to know many different cultures and were impressed by ethical views very different from those that were standardly taken for granted in European society As a defense against the automatic assumption that Western morality is superior and should be imposed on ldquosavagesrdquo many anthropologists argued that since morality is relative to culture no culture can have any basis for regarding its morality as superior to any other culture

Although the motives with which anthropolo-gists put this view forward were admirable they may not have appreciated the implications of the position they were taking The ethical relativist maintains that a statement like ldquoIt is good to enslave people from another tribe if they are captured in warrdquo means simply ldquoIn my society the custom is to enslave people from another tribe if they are cap-tured in warrdquo Hence if one member of the society were to question whether it really was good to enslave people in these circumstances she could be

answered simply by demonstrating that this was indeed the custom ndash for example by showing that for many generations it had been done after every war in which prisoners were captured Thus there is no way for moral reformers to say that an accepted custom is wrong ndash ldquowrongrdquo just means ldquoin accord-ance with an accepted customrdquo

On the other hand when people from two different cultures disagree about an ethical issue then according to the ethical relativist there can be no resolution of the disagreement Indeed strictly there is no disagree-ment If the apparent dispute were over the issue just mentioned then one person would be saying ldquoIn my country it is the custom to enslave people from another tribe if they are captured in warrdquo and the other person would be saying ldquoIn my country it is not the custom to allow one human being to enslave anotherrdquo This is no more a disagreement than such statements as ldquoIn my country people greet each other by rubbing nosesrdquo and ldquoIn my country people greet each other by shaking handsrdquo If ethical relativism is true then it is impossible to say that one culture is right and the other is wrong Bearing in mind that some cultures have practiced slavery or the burning of widows on the funeral pyre of their husbands this is hard to accept

A more promising alternative to both ethical subjectivism and cultural relativism is universal pre-scriptivism an approach to ethics developed by the Oxford philosopher R M Hare Hare argues that the distinctive property of ethical judgments is that they are universalizable In saying this he means that if I make an ethical judgment I must be prepared to state it in universal terms and apply it to all relevantly similar situations By ldquouniversal termsrdquo Hare means those terms that do not refer to a particular individual Thus a proper name cannot be a universal term If for example I were to say ldquoEveryone should do what is in the interests of Mick Jaggerrdquo I would not be making a universal judgment because I have used a proper name The same would be true if I were to say that everyone must do what is in my interests because the personal pronoun ldquomyrdquo is here used to refer to a particular individual myself

It might seem that ruling out particular terms in this way does not take us very far After all one can always describe oneself in universal terms Perhaps

Introduction 3

I canrsquot say that everyone should do what is in my interests but I could say that everyone must do whatever is in the interests of people who hellip and then give a minutely detailed description of myself including the precise location of all my freckles The effect would be the same as saying that everyone should do what is in my interests because there would be no one except me who matches that description But Hare meets this problem very effectively by saying that to prescribe an ethical judgment universally means being prepared to pre-scribe it for all possible circumstances including hypothetical ones So if I were to say that everyone should do what is in the interests of a person with a particular pattern of freckles I must be prepared to prescribe that in the hypothetical situation in which I do not have this pattern of freckles but someone else does I should do what is in the interests of that person Now of course I may say that I should do that since I am confident that I shall never be in such a situation but this simply means that I am being dishonest I am not genuinely prescribing the principle universally

The effect of saying that an ethical judgment must be universalizable for hypothetical as well as actual circumstances is that whenever I make an ethical judgment I can be challenged to put myself in the position of the parties affected and see if I would still be able to accept that judgment Suppose for example that I own a small factory and the cheapest way for me to get rid of some waste is to pour it into a nearby river I do not take water from this river but I know that some villagers living downstream do and the waste may make them ill The requirement that ethical judgments should be universalizable will make it difficult for me to justify my conduct because if I imagine myself in the hypothetical situation of being one of the villagers rather than the factory‐owner I would not accept that the profits of the factory‐owner should outweigh the risk of adverse effects on my health and that of my children In this way Harersquos approach requires us to take into account the interests and preferences of all others affected by our actions Hence it allows for an element of reasoning in ethical deliberation

Since the rightness or wrongness of our actions will on this view depend on the way in which they

affect others Harersquos universal prescriptivism leads to a form of consequentialism ndash that is the view that the rightness of an action depends on its consequences The best‐known form of consequentialism is the clas-sical utilitarianism developed in the late eighteenth century by Jeremy Bentham and popularized in the nineteenth century by John Stuart Mill They held that an action is right if it leads to a greater surplus of happiness over misery than any possible alternative and wrong if it does not By ldquogreater surplus of happinessrdquo the classical utilitarians had in mind the idea of adding up all the pleasure or happiness that resulted from the action and subtracting from that total all the pain or misery to which the action gave rise Naturally in some circumstances it might be possible only to reduce misery and then the right action should be understood as the one that will result in less misery than any possible alternative

The utilitarian view is striking in many ways It puts forward a single principle that it claims can provide the right answer to all ethical dilemmas if only we can predict what the consequences of our actions will be It takes ethics out of the mysterious realm of duties and rules and bases ethical decisions on something that almost everyone understands and values Moreover utilitarianismrsquos single principle is applied universally without fear or favor Bentham said ldquoEach to count for one and none for more than onerdquo by which he meant that the happiness of a com-mon tramp counted for as much as that of a noble and the happiness of an African was no less important than that of a European

Many contemporary consequentialists agree with Bentham to the extent that they think the rightness or wrongness of an action must depend on its conse-quences but they have abandoned the idea that m aximizing net happiness is the ultimate goal Instead they argue that we should seek to bring about w hatever will satisfy the greatest number of desires or preference This variation which is known as ldquop reference utilitarianismrdquo does not regard anything as good except in so far as it is wanted or desired More intense or strongly held preferences would get more weight than weak preferences

Consequentialism offers one important answer to the question of how we should decide what is right and what is wrong but many ethicists reject it The

4 introduction

denial of this view was dramatically presented by Dostoevsky in The Karamazov Brothers

imagine that you are charged with building the edifice of human destiny the ultimate aim of which is to bring people happiness to give them peace and contentment at last but that in order to achieve this it is essential and unavoidable to torture just one little speck of creation that same little child beating her chest with her little fists and imagine that this edifice has to be erected on her unexpiated tears Would you agree to be the architect under those conditions Tell me honestly2

The passage suggests that some things are always wrong no matter what their consequences This has for most of Western history been the prevailing approach to morality at least at the level of what has been officially taught and approved by the institutions of Church and State The ten commandments of the Hebrew scriptures served as a model for much of the Christian era and the Roman Catholic Church built up an elaborate system of morality based on rules to which no exceptions were allowed

Another example of an ethic of rules is that of Immanuel Kant Kantrsquos ethic is based on his ldquocategori-cal imperativerdquo which he states in several distinct for-mulations One is that we must always act so that we can will the maxim of our action to be a universal law This can be interpreted as a form of Harersquos idea of universalizability which we have already encountered Another is that we must always treat other people as ends never as means While these formulations of the categorical imperative might be applied in various ways in Kantrsquos hands they lead to inviolable rules for example against making promises that we do not intend to keep Kant also thought that it was always wrong to tell a lie In response to a critic who sug-gested that this rule has exceptions Kant said that it would be wrong to lie even if someone had taken refuge in your house and a person seeking to murder him came to your door and asked if you knew where he was Modern Kantians often reject this hard-line approach to rules and claim that Kantrsquos categorical imperative did not require him to hold so strictly to the rule against lying

How would a consequentialist ndash for example a classical utilitarian ndash answer Dostoevskyrsquos challenge If answering honestly ndash and if one really could be certain

that this was a sure way and the only way of bringing lasting happiness to all the people of the world ndash utilitarians would have to say yes they would accept the task of being the architect of the happiness of the world at the cost of the childrsquos unexpiated tears For they would point out that the suffering of that child wholly undeserved as it is will be repeated a million‐fold over the next century for other children just as innocent who are victims of starvation disease and brutality So if this one child must be sacrificed to stop all this suffering then terrible as it is the child must be sacrificed

Fantasy apart there can be no architect of the hap-piness of the world The world is too big and complex a place for that But we may attempt to bring about less suffering and more happiness or satisfaction of preferences for people or sentient beings in specific places and circumstances Alternatively we might fol-low a set of principles or rules ndash which could be of varying degrees of rigidity or flexibility Where would such rules come from Kant tried to deduce them from his categorical imperative which in turn he had reached by insisting that the moral law must be based on reason alone without any content from our wants or desires But the problem with trying to deduce morality from reason alone has always been that it becomes an empty formalism that cannot tell us what to do To make it practical it needs to have some addi-tional content and Kantrsquos own attempts to deduce rules of conduct from his categorical imperative are unconvincing

Others following Aristotle have tried to draw on human nature as a source of moral rules What is good they say is what is natural to human beings They then contend that it is natural and right for us to seek certain goods such as knowledge friendship health love and procreation and unnatural and wrong for us to act contrary to these goods This ldquonatural lawrdquo ethic is open to criticism on several points The word ldquonaturalrdquo can be used both descriptively and evalua-tively and the two senses are often mixed together so that value judgments may be smuggled in under the guise of a description The picture of human nature presented by proponents of natural law ethics usually selects only those characteristics of our nature that the proponent considers desirable The fact that our species especially its male members frequently go to war and

Introduction 5

are also prone to commit individual acts of violence against others is no doubt just as much part of our nature as our desire for knowledge but no natural law theorist therefore views these activities as good More generally natural law theory has its origins in an Aristotelian idea of the cosmos in which everything has a goal or ldquoendrdquo which can be deduced from its nature The ldquoendrdquo of a knife is to cut the assumption is that human beings also have an ldquoendrdquo and we will flourish when we live in accordance with the end for which we are suited But this is a pre‐Darwinian view of nature Since Darwin we know that we do not exist for any purpose but are the result of natural selection operating on random mutations over millions of years Hence there is no reason to believe that living accord-ing to nature will produce a harmonious society let alone the best possible state of affairs for human beings

Another way in which it has been claimed that we can come to know what moral principles or rules we should follow is through our intuition In practice this usually means that we adopt conven-tionally accepted moral principles or rules perhaps with some adjustments in order to avoid inconsist-ency or arbitrariness On this view a moral theory should like a scientific theory try to match the data and the data that a moral theory must match is p rovided by our moral intuitions As in science if a plausible theory matches most but not all of the data then the anomalous data might be rejected on the grounds that it is more likely that there was an error in the procedures for gathering that particular set of data than that the theory as a whole is mis-taken But ultimately the test of a theory is its ability to explain the data The problem with applying this model of scientific justification to ethics is that the ldquodatardquo of our moral intuitions is unreliable not just at one or two specific points but as a whole Here the facts that cultural relativists draw upon are rele-vant (even if they do not establish that cultural rela-tivism is the correct response to it) Since we know that our intuitions are strongly influenced by such things as culture and religion they are ill‐suited to serve as the fixed points against which an ethical theory must be tested Even where there is cross‐cultural agreement there may be some aspects of our intuitions on which all cultures unjustifiably favor our own interests over those of others For

example simply because we are all human beings we may have a systematic bias that leads us to give an unjustifiably low moral status to nonhuman a nimals Or because in virtually all known human societies men have taken a greater leadership role than women the moral intuitions of all societies may not adequately reflect the interests of females

Some philosophers think that it is a mistake to base ethics on principles or rules Instead they focus on what it is to be a good person ndash or in the case of the problems with which this book is concerned perhaps on what it is to be a good nurse or doctor or researcher They seek to describe the virtues that a good person or a good member of the relevant profession should possess Moral education then consists of teaching these virtues and discussing how a virtuous person would act in specific situations The question is how-ever whether we can have a notion of what a virtuous person would do in a specific situation without making a prior decision about what it is right to do After all in any particular moral dilemma different virtues may be applicable and even a particular virtue will not always give unequivocal guidance For instance if a terminally ill patient repeatedly asks a nurse or doctor for assistance in dying what response best exemplifies the virtues of a healthcare professional There seems no answer to this question short of an inquiry into whether it is right or wrong to help a patient in such circumstances to die But in that case we seem bound in the end to come back to discuss-ing such issues as whether it is right to follow moral rules or principles or to do what will have the best consequences

In the late twentieth century some feminists offered new criticisms of conventional thought about ethics They argued that the approaches to ethics taken by the influential philosophers of the past ndash all of whom have been male ndash give too much emphasis to abstract principles and the role of reason and give too little attention to personal relationships and the part played by emotion One outcome of these criticisms has been the development of an ldquoethic of carerdquo which is not so much a single ethical theory as a cluster of ways of looking at ethics which put an attitude of c aring for others at the center and seek to avoid r eliance on abstract ethical principles The ethic of care has seemed especially applicable to the work of those

6 introduction

involved in direct patient care and has recently been taken up by a number of nursing theorists as offering a more suitable alternative to other ideas of ethics Not all feminists however support this development Some worry that the adoption of a ldquocarerdquo approach by nurses may reflect and even reinforce stereotypes of women as more emotional and less rational than men They also fear that it could lead to women continuing to carry a disproportionate burden of caring for others to the exclusion of adequately caring for themselves

In this discussion of ethics we have not mentioned anything about religion This may seem odd in view of the close connection that has often been made between religion and ethics but it reflects our belief that despite this historical connection ethics and reli-gion are fundamentally independent Logically ethics is prior to religion If religious believers wish to say that a deity is good or praise her or his creation or deeds they must have a notion of goodness that is independent of their conception of the deity and what she or he does Otherwise they will be saying that the deity is good and when asked what they mean by ldquogoodrdquo they will have to refer back to the deity saying perhaps that ldquogoodrdquo means ldquoin accord-ance with the wishes of the deityrdquo In that case sen-tences such as ldquoGod is goodrdquo would be a meaningless tautology ldquoGod is goodrdquo could mean no more than ldquoGod is in accordance with Godrsquos wishesrdquo As we have already seen there are ideas of what it is for something to be ldquogoodrdquo that are not rooted in any religious belief While religions typically encourage or instruct their followers to obey a particular ethical code it is obvious that others who do not follow any religion can also think and act ethically

To say that ethics is independent of religion is not to deny that theologians or other religious believers may have a role to play in bioethics Religious traditions often have long histories of dealing with ethical dilem-mas and the accumulation of wisdom and experience that they represent can give us valuable insights into particular problems But these insights should be subject to criticism in the way that any other proposals would be If in the end we accept them it is because we have judged them sound not because they are the utterances of a pope a rabbi a mullah or a holy person

Ethics is also independent of the law in the sense that the rightness or wrongness of an act cannot be

settled by its legality or illegality Whether an act is legal or illegal may often be relevant to whether it is right or wrong because it is arguably wrong to break the law other things being equal Many people have thought that this is especially so in a democracy in which everyone has a say in making the law Another reason why the fact that an act is illegal may be a rea-son against doing it is that the legality of an act may affect the consequences that are likely to flow from it If active voluntary euthanasia is illegal then doctors who practice it risk going to jail which will cause them and their families to suffer and also mean that they will no longer be able to help other patients This can be a powerful reason for not practicing voluntary euthanasia when it is against the law but if there is only a very small chance of the offense becoming known or being proved then the weight of this con-sequentialist reason against breaking the law is reduced accordingly Whether we have an ethical obligation to obey the law and if so how much weight should be given to it is itself an issue for ethical argument

Though ethics is independent of the law in the sense just specified laws are subject to evaluation from an ethical perspective Many debates in bioethics focus on questions about what practices should be allowed ndash for example should we allow research on stem cells taken from human embryos sex selection or cloning ndash and committees set up to advise on the ethical social and legal aspects of these questions often recommend legislation to prohibit the activity in question or to allow it to be practiced under some form of regulation Discussing a question at the level of law and public policy however raises somewhat different considerations than a discussion of personal ethics because the consequences of adopting a public policy generally have much wider ramifications than the consequences of a personal choice That is why some healthcare professionals feel justified in assisting a terminally ill patient to die while at the same time opposing the legalization of physician‐assisted suicide Paradoxical as this position may appear ndash and it is certainly open to criticism ndash it is not straightforwardly inconsistent

Naturally many of the essays we have selected reflect the times in which they were written Since bioethics often comments on developments in fast‐moving

Introduction 7

areas of medicine and the biological sciences the factual content of articles in bioethics can become obsolete quite rapidly In preparing this revised edition we have taken the opportunity to cover some new issues and to include some more recent writings We have for example included new mate-rial on genetic enhancement as well as on the use of embryonic human stem cells This edition of the anthology also includes new sections on ethical issues in public health and in the neurosciences Nevertheless an article that has dated in regard to its facts often makes ethical points that are still valid

or worth considering so we have not excluded older articles for this reason

Other articles are dated in a different way During the past few decades we have become more sensitive about the ways in which our language may exclude women or reflect our prejudices regarding race or sexuality We see no merit in trying to disguise past practices on such matters so we have not excluded otherwise valuable works in bioethics on these grounds If they are jar-ring to the modern reader that may be a salutary reminder of the extent to which we all are subject to the conventions and prejudices of our times

Notes

1 See Van Rensselaer Potter Bioethics Bridge to the Future (Englewood Cliffs NJ Prentice‐Hall 1971)

2 The Karamazov Brothers trans Ignat Avsey (Oxford Oxford University Press 1994) vol I part 2 bk 5 ch 4 First published in 1879

Abortion

Part I

Introduction 3

I canrsquot say that everyone should do what is in my interests but I could say that everyone must do whatever is in the interests of people who hellip and then give a minutely detailed description of myself including the precise location of all my freckles The effect would be the same as saying that everyone should do what is in my interests because there would be no one except me who matches that description But Hare meets this problem very effectively by saying that to prescribe an ethical judgment universally means being prepared to pre-scribe it for all possible circumstances including hypothetical ones So if I were to say that everyone should do what is in the interests of a person with a particular pattern of freckles I must be prepared to prescribe that in the hypothetical situation in which I do not have this pattern of freckles but someone else does I should do what is in the interests of that person Now of course I may say that I should do that since I am confident that I shall never be in such a situation but this simply means that I am being dishonest I am not genuinely prescribing the principle universally

The effect of saying that an ethical judgment must be universalizable for hypothetical as well as actual circumstances is that whenever I make an ethical judgment I can be challenged to put myself in the position of the parties affected and see if I would still be able to accept that judgment Suppose for example that I own a small factory and the cheapest way for me to get rid of some waste is to pour it into a nearby river I do not take water from this river but I know that some villagers living downstream do and the waste may make them ill The requirement that ethical judgments should be universalizable will make it difficult for me to justify my conduct because if I imagine myself in the hypothetical situation of being one of the villagers rather than the factory‐owner I would not accept that the profits of the factory‐owner should outweigh the risk of adverse effects on my health and that of my children In this way Harersquos approach requires us to take into account the interests and preferences of all others affected by our actions Hence it allows for an element of reasoning in ethical deliberation

Since the rightness or wrongness of our actions will on this view depend on the way in which they

affect others Harersquos universal prescriptivism leads to a form of consequentialism ndash that is the view that the rightness of an action depends on its consequences The best‐known form of consequentialism is the clas-sical utilitarianism developed in the late eighteenth century by Jeremy Bentham and popularized in the nineteenth century by John Stuart Mill They held that an action is right if it leads to a greater surplus of happiness over misery than any possible alternative and wrong if it does not By ldquogreater surplus of happinessrdquo the classical utilitarians had in mind the idea of adding up all the pleasure or happiness that resulted from the action and subtracting from that total all the pain or misery to which the action gave rise Naturally in some circumstances it might be possible only to reduce misery and then the right action should be understood as the one that will result in less misery than any possible alternative

The utilitarian view is striking in many ways It puts forward a single principle that it claims can provide the right answer to all ethical dilemmas if only we can predict what the consequences of our actions will be It takes ethics out of the mysterious realm of duties and rules and bases ethical decisions on something that almost everyone understands and values Moreover utilitarianismrsquos single principle is applied universally without fear or favor Bentham said ldquoEach to count for one and none for more than onerdquo by which he meant that the happiness of a com-mon tramp counted for as much as that of a noble and the happiness of an African was no less important than that of a European

Many contemporary consequentialists agree with Bentham to the extent that they think the rightness or wrongness of an action must depend on its conse-quences but they have abandoned the idea that m aximizing net happiness is the ultimate goal Instead they argue that we should seek to bring about w hatever will satisfy the greatest number of desires or preference This variation which is known as ldquop reference utilitarianismrdquo does not regard anything as good except in so far as it is wanted or desired More intense or strongly held preferences would get more weight than weak preferences

Consequentialism offers one important answer to the question of how we should decide what is right and what is wrong but many ethicists reject it The

4 introduction

denial of this view was dramatically presented by Dostoevsky in The Karamazov Brothers

imagine that you are charged with building the edifice of human destiny the ultimate aim of which is to bring people happiness to give them peace and contentment at last but that in order to achieve this it is essential and unavoidable to torture just one little speck of creation that same little child beating her chest with her little fists and imagine that this edifice has to be erected on her unexpiated tears Would you agree to be the architect under those conditions Tell me honestly2

The passage suggests that some things are always wrong no matter what their consequences This has for most of Western history been the prevailing approach to morality at least at the level of what has been officially taught and approved by the institutions of Church and State The ten commandments of the Hebrew scriptures served as a model for much of the Christian era and the Roman Catholic Church built up an elaborate system of morality based on rules to which no exceptions were allowed

Another example of an ethic of rules is that of Immanuel Kant Kantrsquos ethic is based on his ldquocategori-cal imperativerdquo which he states in several distinct for-mulations One is that we must always act so that we can will the maxim of our action to be a universal law This can be interpreted as a form of Harersquos idea of universalizability which we have already encountered Another is that we must always treat other people as ends never as means While these formulations of the categorical imperative might be applied in various ways in Kantrsquos hands they lead to inviolable rules for example against making promises that we do not intend to keep Kant also thought that it was always wrong to tell a lie In response to a critic who sug-gested that this rule has exceptions Kant said that it would be wrong to lie even if someone had taken refuge in your house and a person seeking to murder him came to your door and asked if you knew where he was Modern Kantians often reject this hard-line approach to rules and claim that Kantrsquos categorical imperative did not require him to hold so strictly to the rule against lying

How would a consequentialist ndash for example a classical utilitarian ndash answer Dostoevskyrsquos challenge If answering honestly ndash and if one really could be certain

that this was a sure way and the only way of bringing lasting happiness to all the people of the world ndash utilitarians would have to say yes they would accept the task of being the architect of the happiness of the world at the cost of the childrsquos unexpiated tears For they would point out that the suffering of that child wholly undeserved as it is will be repeated a million‐fold over the next century for other children just as innocent who are victims of starvation disease and brutality So if this one child must be sacrificed to stop all this suffering then terrible as it is the child must be sacrificed

Fantasy apart there can be no architect of the hap-piness of the world The world is too big and complex a place for that But we may attempt to bring about less suffering and more happiness or satisfaction of preferences for people or sentient beings in specific places and circumstances Alternatively we might fol-low a set of principles or rules ndash which could be of varying degrees of rigidity or flexibility Where would such rules come from Kant tried to deduce them from his categorical imperative which in turn he had reached by insisting that the moral law must be based on reason alone without any content from our wants or desires But the problem with trying to deduce morality from reason alone has always been that it becomes an empty formalism that cannot tell us what to do To make it practical it needs to have some addi-tional content and Kantrsquos own attempts to deduce rules of conduct from his categorical imperative are unconvincing

Others following Aristotle have tried to draw on human nature as a source of moral rules What is good they say is what is natural to human beings They then contend that it is natural and right for us to seek certain goods such as knowledge friendship health love and procreation and unnatural and wrong for us to act contrary to these goods This ldquonatural lawrdquo ethic is open to criticism on several points The word ldquonaturalrdquo can be used both descriptively and evalua-tively and the two senses are often mixed together so that value judgments may be smuggled in under the guise of a description The picture of human nature presented by proponents of natural law ethics usually selects only those characteristics of our nature that the proponent considers desirable The fact that our species especially its male members frequently go to war and

Introduction 5

are also prone to commit individual acts of violence against others is no doubt just as much part of our nature as our desire for knowledge but no natural law theorist therefore views these activities as good More generally natural law theory has its origins in an Aristotelian idea of the cosmos in which everything has a goal or ldquoendrdquo which can be deduced from its nature The ldquoendrdquo of a knife is to cut the assumption is that human beings also have an ldquoendrdquo and we will flourish when we live in accordance with the end for which we are suited But this is a pre‐Darwinian view of nature Since Darwin we know that we do not exist for any purpose but are the result of natural selection operating on random mutations over millions of years Hence there is no reason to believe that living accord-ing to nature will produce a harmonious society let alone the best possible state of affairs for human beings

Another way in which it has been claimed that we can come to know what moral principles or rules we should follow is through our intuition In practice this usually means that we adopt conven-tionally accepted moral principles or rules perhaps with some adjustments in order to avoid inconsist-ency or arbitrariness On this view a moral theory should like a scientific theory try to match the data and the data that a moral theory must match is p rovided by our moral intuitions As in science if a plausible theory matches most but not all of the data then the anomalous data might be rejected on the grounds that it is more likely that there was an error in the procedures for gathering that particular set of data than that the theory as a whole is mis-taken But ultimately the test of a theory is its ability to explain the data The problem with applying this model of scientific justification to ethics is that the ldquodatardquo of our moral intuitions is unreliable not just at one or two specific points but as a whole Here the facts that cultural relativists draw upon are rele-vant (even if they do not establish that cultural rela-tivism is the correct response to it) Since we know that our intuitions are strongly influenced by such things as culture and religion they are ill‐suited to serve as the fixed points against which an ethical theory must be tested Even where there is cross‐cultural agreement there may be some aspects of our intuitions on which all cultures unjustifiably favor our own interests over those of others For

example simply because we are all human beings we may have a systematic bias that leads us to give an unjustifiably low moral status to nonhuman a nimals Or because in virtually all known human societies men have taken a greater leadership role than women the moral intuitions of all societies may not adequately reflect the interests of females

Some philosophers think that it is a mistake to base ethics on principles or rules Instead they focus on what it is to be a good person ndash or in the case of the problems with which this book is concerned perhaps on what it is to be a good nurse or doctor or researcher They seek to describe the virtues that a good person or a good member of the relevant profession should possess Moral education then consists of teaching these virtues and discussing how a virtuous person would act in specific situations The question is how-ever whether we can have a notion of what a virtuous person would do in a specific situation without making a prior decision about what it is right to do After all in any particular moral dilemma different virtues may be applicable and even a particular virtue will not always give unequivocal guidance For instance if a terminally ill patient repeatedly asks a nurse or doctor for assistance in dying what response best exemplifies the virtues of a healthcare professional There seems no answer to this question short of an inquiry into whether it is right or wrong to help a patient in such circumstances to die But in that case we seem bound in the end to come back to discuss-ing such issues as whether it is right to follow moral rules or principles or to do what will have the best consequences

In the late twentieth century some feminists offered new criticisms of conventional thought about ethics They argued that the approaches to ethics taken by the influential philosophers of the past ndash all of whom have been male ndash give too much emphasis to abstract principles and the role of reason and give too little attention to personal relationships and the part played by emotion One outcome of these criticisms has been the development of an ldquoethic of carerdquo which is not so much a single ethical theory as a cluster of ways of looking at ethics which put an attitude of c aring for others at the center and seek to avoid r eliance on abstract ethical principles The ethic of care has seemed especially applicable to the work of those

6 introduction

involved in direct patient care and has recently been taken up by a number of nursing theorists as offering a more suitable alternative to other ideas of ethics Not all feminists however support this development Some worry that the adoption of a ldquocarerdquo approach by nurses may reflect and even reinforce stereotypes of women as more emotional and less rational than men They also fear that it could lead to women continuing to carry a disproportionate burden of caring for others to the exclusion of adequately caring for themselves

In this discussion of ethics we have not mentioned anything about religion This may seem odd in view of the close connection that has often been made between religion and ethics but it reflects our belief that despite this historical connection ethics and reli-gion are fundamentally independent Logically ethics is prior to religion If religious believers wish to say that a deity is good or praise her or his creation or deeds they must have a notion of goodness that is independent of their conception of the deity and what she or he does Otherwise they will be saying that the deity is good and when asked what they mean by ldquogoodrdquo they will have to refer back to the deity saying perhaps that ldquogoodrdquo means ldquoin accord-ance with the wishes of the deityrdquo In that case sen-tences such as ldquoGod is goodrdquo would be a meaningless tautology ldquoGod is goodrdquo could mean no more than ldquoGod is in accordance with Godrsquos wishesrdquo As we have already seen there are ideas of what it is for something to be ldquogoodrdquo that are not rooted in any religious belief While religions typically encourage or instruct their followers to obey a particular ethical code it is obvious that others who do not follow any religion can also think and act ethically

To say that ethics is independent of religion is not to deny that theologians or other religious believers may have a role to play in bioethics Religious traditions often have long histories of dealing with ethical dilem-mas and the accumulation of wisdom and experience that they represent can give us valuable insights into particular problems But these insights should be subject to criticism in the way that any other proposals would be If in the end we accept them it is because we have judged them sound not because they are the utterances of a pope a rabbi a mullah or a holy person

Ethics is also independent of the law in the sense that the rightness or wrongness of an act cannot be

settled by its legality or illegality Whether an act is legal or illegal may often be relevant to whether it is right or wrong because it is arguably wrong to break the law other things being equal Many people have thought that this is especially so in a democracy in which everyone has a say in making the law Another reason why the fact that an act is illegal may be a rea-son against doing it is that the legality of an act may affect the consequences that are likely to flow from it If active voluntary euthanasia is illegal then doctors who practice it risk going to jail which will cause them and their families to suffer and also mean that they will no longer be able to help other patients This can be a powerful reason for not practicing voluntary euthanasia when it is against the law but if there is only a very small chance of the offense becoming known or being proved then the weight of this con-sequentialist reason against breaking the law is reduced accordingly Whether we have an ethical obligation to obey the law and if so how much weight should be given to it is itself an issue for ethical argument

Though ethics is independent of the law in the sense just specified laws are subject to evaluation from an ethical perspective Many debates in bioethics focus on questions about what practices should be allowed ndash for example should we allow research on stem cells taken from human embryos sex selection or cloning ndash and committees set up to advise on the ethical social and legal aspects of these questions often recommend legislation to prohibit the activity in question or to allow it to be practiced under some form of regulation Discussing a question at the level of law and public policy however raises somewhat different considerations than a discussion of personal ethics because the consequences of adopting a public policy generally have much wider ramifications than the consequences of a personal choice That is why some healthcare professionals feel justified in assisting a terminally ill patient to die while at the same time opposing the legalization of physician‐assisted suicide Paradoxical as this position may appear ndash and it is certainly open to criticism ndash it is not straightforwardly inconsistent

Naturally many of the essays we have selected reflect the times in which they were written Since bioethics often comments on developments in fast‐moving

Introduction 7

areas of medicine and the biological sciences the factual content of articles in bioethics can become obsolete quite rapidly In preparing this revised edition we have taken the opportunity to cover some new issues and to include some more recent writings We have for example included new mate-rial on genetic enhancement as well as on the use of embryonic human stem cells This edition of the anthology also includes new sections on ethical issues in public health and in the neurosciences Nevertheless an article that has dated in regard to its facts often makes ethical points that are still valid

or worth considering so we have not excluded older articles for this reason

Other articles are dated in a different way During the past few decades we have become more sensitive about the ways in which our language may exclude women or reflect our prejudices regarding race or sexuality We see no merit in trying to disguise past practices on such matters so we have not excluded otherwise valuable works in bioethics on these grounds If they are jar-ring to the modern reader that may be a salutary reminder of the extent to which we all are subject to the conventions and prejudices of our times

Notes

1 See Van Rensselaer Potter Bioethics Bridge to the Future (Englewood Cliffs NJ Prentice‐Hall 1971)

2 The Karamazov Brothers trans Ignat Avsey (Oxford Oxford University Press 1994) vol I part 2 bk 5 ch 4 First published in 1879

Abortion

Part I

4 introduction

denial of this view was dramatically presented by Dostoevsky in The Karamazov Brothers

imagine that you are charged with building the edifice of human destiny the ultimate aim of which is to bring people happiness to give them peace and contentment at last but that in order to achieve this it is essential and unavoidable to torture just one little speck of creation that same little child beating her chest with her little fists and imagine that this edifice has to be erected on her unexpiated tears Would you agree to be the architect under those conditions Tell me honestly2

The passage suggests that some things are always wrong no matter what their consequences This has for most of Western history been the prevailing approach to morality at least at the level of what has been officially taught and approved by the institutions of Church and State The ten commandments of the Hebrew scriptures served as a model for much of the Christian era and the Roman Catholic Church built up an elaborate system of morality based on rules to which no exceptions were allowed

Another example of an ethic of rules is that of Immanuel Kant Kantrsquos ethic is based on his ldquocategori-cal imperativerdquo which he states in several distinct for-mulations One is that we must always act so that we can will the maxim of our action to be a universal law This can be interpreted as a form of Harersquos idea of universalizability which we have already encountered Another is that we must always treat other people as ends never as means While these formulations of the categorical imperative might be applied in various ways in Kantrsquos hands they lead to inviolable rules for example against making promises that we do not intend to keep Kant also thought that it was always wrong to tell a lie In response to a critic who sug-gested that this rule has exceptions Kant said that it would be wrong to lie even if someone had taken refuge in your house and a person seeking to murder him came to your door and asked if you knew where he was Modern Kantians often reject this hard-line approach to rules and claim that Kantrsquos categorical imperative did not require him to hold so strictly to the rule against lying

How would a consequentialist ndash for example a classical utilitarian ndash answer Dostoevskyrsquos challenge If answering honestly ndash and if one really could be certain

that this was a sure way and the only way of bringing lasting happiness to all the people of the world ndash utilitarians would have to say yes they would accept the task of being the architect of the happiness of the world at the cost of the childrsquos unexpiated tears For they would point out that the suffering of that child wholly undeserved as it is will be repeated a million‐fold over the next century for other children just as innocent who are victims of starvation disease and brutality So if this one child must be sacrificed to stop all this suffering then terrible as it is the child must be sacrificed

Fantasy apart there can be no architect of the hap-piness of the world The world is too big and complex a place for that But we may attempt to bring about less suffering and more happiness or satisfaction of preferences for people or sentient beings in specific places and circumstances Alternatively we might fol-low a set of principles or rules ndash which could be of varying degrees of rigidity or flexibility Where would such rules come from Kant tried to deduce them from his categorical imperative which in turn he had reached by insisting that the moral law must be based on reason alone without any content from our wants or desires But the problem with trying to deduce morality from reason alone has always been that it becomes an empty formalism that cannot tell us what to do To make it practical it needs to have some addi-tional content and Kantrsquos own attempts to deduce rules of conduct from his categorical imperative are unconvincing

Others following Aristotle have tried to draw on human nature as a source of moral rules What is good they say is what is natural to human beings They then contend that it is natural and right for us to seek certain goods such as knowledge friendship health love and procreation and unnatural and wrong for us to act contrary to these goods This ldquonatural lawrdquo ethic is open to criticism on several points The word ldquonaturalrdquo can be used both descriptively and evalua-tively and the two senses are often mixed together so that value judgments may be smuggled in under the guise of a description The picture of human nature presented by proponents of natural law ethics usually selects only those characteristics of our nature that the proponent considers desirable The fact that our species especially its male members frequently go to war and

Introduction 5

are also prone to commit individual acts of violence against others is no doubt just as much part of our nature as our desire for knowledge but no natural law theorist therefore views these activities as good More generally natural law theory has its origins in an Aristotelian idea of the cosmos in which everything has a goal or ldquoendrdquo which can be deduced from its nature The ldquoendrdquo of a knife is to cut the assumption is that human beings also have an ldquoendrdquo and we will flourish when we live in accordance with the end for which we are suited But this is a pre‐Darwinian view of nature Since Darwin we know that we do not exist for any purpose but are the result of natural selection operating on random mutations over millions of years Hence there is no reason to believe that living accord-ing to nature will produce a harmonious society let alone the best possible state of affairs for human beings

Another way in which it has been claimed that we can come to know what moral principles or rules we should follow is through our intuition In practice this usually means that we adopt conven-tionally accepted moral principles or rules perhaps with some adjustments in order to avoid inconsist-ency or arbitrariness On this view a moral theory should like a scientific theory try to match the data and the data that a moral theory must match is p rovided by our moral intuitions As in science if a plausible theory matches most but not all of the data then the anomalous data might be rejected on the grounds that it is more likely that there was an error in the procedures for gathering that particular set of data than that the theory as a whole is mis-taken But ultimately the test of a theory is its ability to explain the data The problem with applying this model of scientific justification to ethics is that the ldquodatardquo of our moral intuitions is unreliable not just at one or two specific points but as a whole Here the facts that cultural relativists draw upon are rele-vant (even if they do not establish that cultural rela-tivism is the correct response to it) Since we know that our intuitions are strongly influenced by such things as culture and religion they are ill‐suited to serve as the fixed points against which an ethical theory must be tested Even where there is cross‐cultural agreement there may be some aspects of our intuitions on which all cultures unjustifiably favor our own interests over those of others For

example simply because we are all human beings we may have a systematic bias that leads us to give an unjustifiably low moral status to nonhuman a nimals Or because in virtually all known human societies men have taken a greater leadership role than women the moral intuitions of all societies may not adequately reflect the interests of females

Some philosophers think that it is a mistake to base ethics on principles or rules Instead they focus on what it is to be a good person ndash or in the case of the problems with which this book is concerned perhaps on what it is to be a good nurse or doctor or researcher They seek to describe the virtues that a good person or a good member of the relevant profession should possess Moral education then consists of teaching these virtues and discussing how a virtuous person would act in specific situations The question is how-ever whether we can have a notion of what a virtuous person would do in a specific situation without making a prior decision about what it is right to do After all in any particular moral dilemma different virtues may be applicable and even a particular virtue will not always give unequivocal guidance For instance if a terminally ill patient repeatedly asks a nurse or doctor for assistance in dying what response best exemplifies the virtues of a healthcare professional There seems no answer to this question short of an inquiry into whether it is right or wrong to help a patient in such circumstances to die But in that case we seem bound in the end to come back to discuss-ing such issues as whether it is right to follow moral rules or principles or to do what will have the best consequences

In the late twentieth century some feminists offered new criticisms of conventional thought about ethics They argued that the approaches to ethics taken by the influential philosophers of the past ndash all of whom have been male ndash give too much emphasis to abstract principles and the role of reason and give too little attention to personal relationships and the part played by emotion One outcome of these criticisms has been the development of an ldquoethic of carerdquo which is not so much a single ethical theory as a cluster of ways of looking at ethics which put an attitude of c aring for others at the center and seek to avoid r eliance on abstract ethical principles The ethic of care has seemed especially applicable to the work of those

6 introduction

involved in direct patient care and has recently been taken up by a number of nursing theorists as offering a more suitable alternative to other ideas of ethics Not all feminists however support this development Some worry that the adoption of a ldquocarerdquo approach by nurses may reflect and even reinforce stereotypes of women as more emotional and less rational than men They also fear that it could lead to women continuing to carry a disproportionate burden of caring for others to the exclusion of adequately caring for themselves

In this discussion of ethics we have not mentioned anything about religion This may seem odd in view of the close connection that has often been made between religion and ethics but it reflects our belief that despite this historical connection ethics and reli-gion are fundamentally independent Logically ethics is prior to religion If religious believers wish to say that a deity is good or praise her or his creation or deeds they must have a notion of goodness that is independent of their conception of the deity and what she or he does Otherwise they will be saying that the deity is good and when asked what they mean by ldquogoodrdquo they will have to refer back to the deity saying perhaps that ldquogoodrdquo means ldquoin accord-ance with the wishes of the deityrdquo In that case sen-tences such as ldquoGod is goodrdquo would be a meaningless tautology ldquoGod is goodrdquo could mean no more than ldquoGod is in accordance with Godrsquos wishesrdquo As we have already seen there are ideas of what it is for something to be ldquogoodrdquo that are not rooted in any religious belief While religions typically encourage or instruct their followers to obey a particular ethical code it is obvious that others who do not follow any religion can also think and act ethically

To say that ethics is independent of religion is not to deny that theologians or other religious believers may have a role to play in bioethics Religious traditions often have long histories of dealing with ethical dilem-mas and the accumulation of wisdom and experience that they represent can give us valuable insights into particular problems But these insights should be subject to criticism in the way that any other proposals would be If in the end we accept them it is because we have judged them sound not because they are the utterances of a pope a rabbi a mullah or a holy person

Ethics is also independent of the law in the sense that the rightness or wrongness of an act cannot be

settled by its legality or illegality Whether an act is legal or illegal may often be relevant to whether it is right or wrong because it is arguably wrong to break the law other things being equal Many people have thought that this is especially so in a democracy in which everyone has a say in making the law Another reason why the fact that an act is illegal may be a rea-son against doing it is that the legality of an act may affect the consequences that are likely to flow from it If active voluntary euthanasia is illegal then doctors who practice it risk going to jail which will cause them and their families to suffer and also mean that they will no longer be able to help other patients This can be a powerful reason for not practicing voluntary euthanasia when it is against the law but if there is only a very small chance of the offense becoming known or being proved then the weight of this con-sequentialist reason against breaking the law is reduced accordingly Whether we have an ethical obligation to obey the law and if so how much weight should be given to it is itself an issue for ethical argument

Though ethics is independent of the law in the sense just specified laws are subject to evaluation from an ethical perspective Many debates in bioethics focus on questions about what practices should be allowed ndash for example should we allow research on stem cells taken from human embryos sex selection or cloning ndash and committees set up to advise on the ethical social and legal aspects of these questions often recommend legislation to prohibit the activity in question or to allow it to be practiced under some form of regulation Discussing a question at the level of law and public policy however raises somewhat different considerations than a discussion of personal ethics because the consequences of adopting a public policy generally have much wider ramifications than the consequences of a personal choice That is why some healthcare professionals feel justified in assisting a terminally ill patient to die while at the same time opposing the legalization of physician‐assisted suicide Paradoxical as this position may appear ndash and it is certainly open to criticism ndash it is not straightforwardly inconsistent

Naturally many of the essays we have selected reflect the times in which they were written Since bioethics often comments on developments in fast‐moving

Introduction 7

areas of medicine and the biological sciences the factual content of articles in bioethics can become obsolete quite rapidly In preparing this revised edition we have taken the opportunity to cover some new issues and to include some more recent writings We have for example included new mate-rial on genetic enhancement as well as on the use of embryonic human stem cells This edition of the anthology also includes new sections on ethical issues in public health and in the neurosciences Nevertheless an article that has dated in regard to its facts often makes ethical points that are still valid

or worth considering so we have not excluded older articles for this reason

Other articles are dated in a different way During the past few decades we have become more sensitive about the ways in which our language may exclude women or reflect our prejudices regarding race or sexuality We see no merit in trying to disguise past practices on such matters so we have not excluded otherwise valuable works in bioethics on these grounds If they are jar-ring to the modern reader that may be a salutary reminder of the extent to which we all are subject to the conventions and prejudices of our times

Notes

1 See Van Rensselaer Potter Bioethics Bridge to the Future (Englewood Cliffs NJ Prentice‐Hall 1971)

2 The Karamazov Brothers trans Ignat Avsey (Oxford Oxford University Press 1994) vol I part 2 bk 5 ch 4 First published in 1879

Abortion

Part I

Introduction 5

are also prone to commit individual acts of violence against others is no doubt just as much part of our nature as our desire for knowledge but no natural law theorist therefore views these activities as good More generally natural law theory has its origins in an Aristotelian idea of the cosmos in which everything has a goal or ldquoendrdquo which can be deduced from its nature The ldquoendrdquo of a knife is to cut the assumption is that human beings also have an ldquoendrdquo and we will flourish when we live in accordance with the end for which we are suited But this is a pre‐Darwinian view of nature Since Darwin we know that we do not exist for any purpose but are the result of natural selection operating on random mutations over millions of years Hence there is no reason to believe that living accord-ing to nature will produce a harmonious society let alone the best possible state of affairs for human beings

Another way in which it has been claimed that we can come to know what moral principles or rules we should follow is through our intuition In practice this usually means that we adopt conven-tionally accepted moral principles or rules perhaps with some adjustments in order to avoid inconsist-ency or arbitrariness On this view a moral theory should like a scientific theory try to match the data and the data that a moral theory must match is p rovided by our moral intuitions As in science if a plausible theory matches most but not all of the data then the anomalous data might be rejected on the grounds that it is more likely that there was an error in the procedures for gathering that particular set of data than that the theory as a whole is mis-taken But ultimately the test of a theory is its ability to explain the data The problem with applying this model of scientific justification to ethics is that the ldquodatardquo of our moral intuitions is unreliable not just at one or two specific points but as a whole Here the facts that cultural relativists draw upon are rele-vant (even if they do not establish that cultural rela-tivism is the correct response to it) Since we know that our intuitions are strongly influenced by such things as culture and religion they are ill‐suited to serve as the fixed points against which an ethical theory must be tested Even where there is cross‐cultural agreement there may be some aspects of our intuitions on which all cultures unjustifiably favor our own interests over those of others For

example simply because we are all human beings we may have a systematic bias that leads us to give an unjustifiably low moral status to nonhuman a nimals Or because in virtually all known human societies men have taken a greater leadership role than women the moral intuitions of all societies may not adequately reflect the interests of females

Some philosophers think that it is a mistake to base ethics on principles or rules Instead they focus on what it is to be a good person ndash or in the case of the problems with which this book is concerned perhaps on what it is to be a good nurse or doctor or researcher They seek to describe the virtues that a good person or a good member of the relevant profession should possess Moral education then consists of teaching these virtues and discussing how a virtuous person would act in specific situations The question is how-ever whether we can have a notion of what a virtuous person would do in a specific situation without making a prior decision about what it is right to do After all in any particular moral dilemma different virtues may be applicable and even a particular virtue will not always give unequivocal guidance For instance if a terminally ill patient repeatedly asks a nurse or doctor for assistance in dying what response best exemplifies the virtues of a healthcare professional There seems no answer to this question short of an inquiry into whether it is right or wrong to help a patient in such circumstances to die But in that case we seem bound in the end to come back to discuss-ing such issues as whether it is right to follow moral rules or principles or to do what will have the best consequences

In the late twentieth century some feminists offered new criticisms of conventional thought about ethics They argued that the approaches to ethics taken by the influential philosophers of the past ndash all of whom have been male ndash give too much emphasis to abstract principles and the role of reason and give too little attention to personal relationships and the part played by emotion One outcome of these criticisms has been the development of an ldquoethic of carerdquo which is not so much a single ethical theory as a cluster of ways of looking at ethics which put an attitude of c aring for others at the center and seek to avoid r eliance on abstract ethical principles The ethic of care has seemed especially applicable to the work of those

6 introduction

involved in direct patient care and has recently been taken up by a number of nursing theorists as offering a more suitable alternative to other ideas of ethics Not all feminists however support this development Some worry that the adoption of a ldquocarerdquo approach by nurses may reflect and even reinforce stereotypes of women as more emotional and less rational than men They also fear that it could lead to women continuing to carry a disproportionate burden of caring for others to the exclusion of adequately caring for themselves

In this discussion of ethics we have not mentioned anything about religion This may seem odd in view of the close connection that has often been made between religion and ethics but it reflects our belief that despite this historical connection ethics and reli-gion are fundamentally independent Logically ethics is prior to religion If religious believers wish to say that a deity is good or praise her or his creation or deeds they must have a notion of goodness that is independent of their conception of the deity and what she or he does Otherwise they will be saying that the deity is good and when asked what they mean by ldquogoodrdquo they will have to refer back to the deity saying perhaps that ldquogoodrdquo means ldquoin accord-ance with the wishes of the deityrdquo In that case sen-tences such as ldquoGod is goodrdquo would be a meaningless tautology ldquoGod is goodrdquo could mean no more than ldquoGod is in accordance with Godrsquos wishesrdquo As we have already seen there are ideas of what it is for something to be ldquogoodrdquo that are not rooted in any religious belief While religions typically encourage or instruct their followers to obey a particular ethical code it is obvious that others who do not follow any religion can also think and act ethically

To say that ethics is independent of religion is not to deny that theologians or other religious believers may have a role to play in bioethics Religious traditions often have long histories of dealing with ethical dilem-mas and the accumulation of wisdom and experience that they represent can give us valuable insights into particular problems But these insights should be subject to criticism in the way that any other proposals would be If in the end we accept them it is because we have judged them sound not because they are the utterances of a pope a rabbi a mullah or a holy person

Ethics is also independent of the law in the sense that the rightness or wrongness of an act cannot be

settled by its legality or illegality Whether an act is legal or illegal may often be relevant to whether it is right or wrong because it is arguably wrong to break the law other things being equal Many people have thought that this is especially so in a democracy in which everyone has a say in making the law Another reason why the fact that an act is illegal may be a rea-son against doing it is that the legality of an act may affect the consequences that are likely to flow from it If active voluntary euthanasia is illegal then doctors who practice it risk going to jail which will cause them and their families to suffer and also mean that they will no longer be able to help other patients This can be a powerful reason for not practicing voluntary euthanasia when it is against the law but if there is only a very small chance of the offense becoming known or being proved then the weight of this con-sequentialist reason against breaking the law is reduced accordingly Whether we have an ethical obligation to obey the law and if so how much weight should be given to it is itself an issue for ethical argument

Though ethics is independent of the law in the sense just specified laws are subject to evaluation from an ethical perspective Many debates in bioethics focus on questions about what practices should be allowed ndash for example should we allow research on stem cells taken from human embryos sex selection or cloning ndash and committees set up to advise on the ethical social and legal aspects of these questions often recommend legislation to prohibit the activity in question or to allow it to be practiced under some form of regulation Discussing a question at the level of law and public policy however raises somewhat different considerations than a discussion of personal ethics because the consequences of adopting a public policy generally have much wider ramifications than the consequences of a personal choice That is why some healthcare professionals feel justified in assisting a terminally ill patient to die while at the same time opposing the legalization of physician‐assisted suicide Paradoxical as this position may appear ndash and it is certainly open to criticism ndash it is not straightforwardly inconsistent

Naturally many of the essays we have selected reflect the times in which they were written Since bioethics often comments on developments in fast‐moving

Introduction 7

areas of medicine and the biological sciences the factual content of articles in bioethics can become obsolete quite rapidly In preparing this revised edition we have taken the opportunity to cover some new issues and to include some more recent writings We have for example included new mate-rial on genetic enhancement as well as on the use of embryonic human stem cells This edition of the anthology also includes new sections on ethical issues in public health and in the neurosciences Nevertheless an article that has dated in regard to its facts often makes ethical points that are still valid

or worth considering so we have not excluded older articles for this reason

Other articles are dated in a different way During the past few decades we have become more sensitive about the ways in which our language may exclude women or reflect our prejudices regarding race or sexuality We see no merit in trying to disguise past practices on such matters so we have not excluded otherwise valuable works in bioethics on these grounds If they are jar-ring to the modern reader that may be a salutary reminder of the extent to which we all are subject to the conventions and prejudices of our times

Notes

1 See Van Rensselaer Potter Bioethics Bridge to the Future (Englewood Cliffs NJ Prentice‐Hall 1971)

2 The Karamazov Brothers trans Ignat Avsey (Oxford Oxford University Press 1994) vol I part 2 bk 5 ch 4 First published in 1879

Abortion

Part I

6 introduction

involved in direct patient care and has recently been taken up by a number of nursing theorists as offering a more suitable alternative to other ideas of ethics Not all feminists however support this development Some worry that the adoption of a ldquocarerdquo approach by nurses may reflect and even reinforce stereotypes of women as more emotional and less rational than men They also fear that it could lead to women continuing to carry a disproportionate burden of caring for others to the exclusion of adequately caring for themselves

In this discussion of ethics we have not mentioned anything about religion This may seem odd in view of the close connection that has often been made between religion and ethics but it reflects our belief that despite this historical connection ethics and reli-gion are fundamentally independent Logically ethics is prior to religion If religious believers wish to say that a deity is good or praise her or his creation or deeds they must have a notion of goodness that is independent of their conception of the deity and what she or he does Otherwise they will be saying that the deity is good and when asked what they mean by ldquogoodrdquo they will have to refer back to the deity saying perhaps that ldquogoodrdquo means ldquoin accord-ance with the wishes of the deityrdquo In that case sen-tences such as ldquoGod is goodrdquo would be a meaningless tautology ldquoGod is goodrdquo could mean no more than ldquoGod is in accordance with Godrsquos wishesrdquo As we have already seen there are ideas of what it is for something to be ldquogoodrdquo that are not rooted in any religious belief While religions typically encourage or instruct their followers to obey a particular ethical code it is obvious that others who do not follow any religion can also think and act ethically

To say that ethics is independent of religion is not to deny that theologians or other religious believers may have a role to play in bioethics Religious traditions often have long histories of dealing with ethical dilem-mas and the accumulation of wisdom and experience that they represent can give us valuable insights into particular problems But these insights should be subject to criticism in the way that any other proposals would be If in the end we accept them it is because we have judged them sound not because they are the utterances of a pope a rabbi a mullah or a holy person

Ethics is also independent of the law in the sense that the rightness or wrongness of an act cannot be

settled by its legality or illegality Whether an act is legal or illegal may often be relevant to whether it is right or wrong because it is arguably wrong to break the law other things being equal Many people have thought that this is especially so in a democracy in which everyone has a say in making the law Another reason why the fact that an act is illegal may be a rea-son against doing it is that the legality of an act may affect the consequences that are likely to flow from it If active voluntary euthanasia is illegal then doctors who practice it risk going to jail which will cause them and their families to suffer and also mean that they will no longer be able to help other patients This can be a powerful reason for not practicing voluntary euthanasia when it is against the law but if there is only a very small chance of the offense becoming known or being proved then the weight of this con-sequentialist reason against breaking the law is reduced accordingly Whether we have an ethical obligation to obey the law and if so how much weight should be given to it is itself an issue for ethical argument

Though ethics is independent of the law in the sense just specified laws are subject to evaluation from an ethical perspective Many debates in bioethics focus on questions about what practices should be allowed ndash for example should we allow research on stem cells taken from human embryos sex selection or cloning ndash and committees set up to advise on the ethical social and legal aspects of these questions often recommend legislation to prohibit the activity in question or to allow it to be practiced under some form of regulation Discussing a question at the level of law and public policy however raises somewhat different considerations than a discussion of personal ethics because the consequences of adopting a public policy generally have much wider ramifications than the consequences of a personal choice That is why some healthcare professionals feel justified in assisting a terminally ill patient to die while at the same time opposing the legalization of physician‐assisted suicide Paradoxical as this position may appear ndash and it is certainly open to criticism ndash it is not straightforwardly inconsistent

Naturally many of the essays we have selected reflect the times in which they were written Since bioethics often comments on developments in fast‐moving

Introduction 7

areas of medicine and the biological sciences the factual content of articles in bioethics can become obsolete quite rapidly In preparing this revised edition we have taken the opportunity to cover some new issues and to include some more recent writings We have for example included new mate-rial on genetic enhancement as well as on the use of embryonic human stem cells This edition of the anthology also includes new sections on ethical issues in public health and in the neurosciences Nevertheless an article that has dated in regard to its facts often makes ethical points that are still valid

or worth considering so we have not excluded older articles for this reason

Other articles are dated in a different way During the past few decades we have become more sensitive about the ways in which our language may exclude women or reflect our prejudices regarding race or sexuality We see no merit in trying to disguise past practices on such matters so we have not excluded otherwise valuable works in bioethics on these grounds If they are jar-ring to the modern reader that may be a salutary reminder of the extent to which we all are subject to the conventions and prejudices of our times

Notes

1 See Van Rensselaer Potter Bioethics Bridge to the Future (Englewood Cliffs NJ Prentice‐Hall 1971)

2 The Karamazov Brothers trans Ignat Avsey (Oxford Oxford University Press 1994) vol I part 2 bk 5 ch 4 First published in 1879

Abortion

Part I

Introduction 7

areas of medicine and the biological sciences the factual content of articles in bioethics can become obsolete quite rapidly In preparing this revised edition we have taken the opportunity to cover some new issues and to include some more recent writings We have for example included new mate-rial on genetic enhancement as well as on the use of embryonic human stem cells This edition of the anthology also includes new sections on ethical issues in public health and in the neurosciences Nevertheless an article that has dated in regard to its facts often makes ethical points that are still valid

or worth considering so we have not excluded older articles for this reason

Other articles are dated in a different way During the past few decades we have become more sensitive about the ways in which our language may exclude women or reflect our prejudices regarding race or sexuality We see no merit in trying to disguise past practices on such matters so we have not excluded otherwise valuable works in bioethics on these grounds If they are jar-ring to the modern reader that may be a salutary reminder of the extent to which we all are subject to the conventions and prejudices of our times

Notes

1 See Van Rensselaer Potter Bioethics Bridge to the Future (Englewood Cliffs NJ Prentice‐Hall 1971)

2 The Karamazov Brothers trans Ignat Avsey (Oxford Oxford University Press 1994) vol I part 2 bk 5 ch 4 First published in 1879

Abortion

Part I

Abortion

Part I